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Essentials of
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DIAGNOSIS&TREATMENT
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Essentials of
...- _.-._.._. .._..._- ..._.- DIAGNOSIS&TREATMENT
Second Edition
a LANGE medical book
Lawrence M. Tierney, Jr., MD
Professor of Medicine
University of California, San Francisco
Associate Chief of Med ica I Services
Veterans Affairs Medical Center
San Francisco, California
Sanjay Saini, MD, MPH
Assistant Professor of Medicine
Division of General Medicine
University of Michigan Medical School
Research Scientist
Ann Arbor Veterans Affairs Medical Center
Ann Arbor, Michigan
Mary A. Whooley, MD
Assistant Professor of Medicine
University of California, San Francisco
Section of General Internal Medicine
Veterans Affairs Medical Center
San Francisco, California
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Contents
Contributors .
Preface .
. ix
. xiii
1. Cardiovascular Diseases. . . .. 1
2. Pulmonary Diseases. . ..... 37
3. Gastrointestinal Diseases. .64
4. Hepatobiliary Disorders. .90
5. Hematologic Diseases. . . . . . . . . . . . . . . . . . . 106
6. Rheumatologic & AUloimmune Disorders. . 143
7. Endocrine Disorders. . . 174
8. Infectious Diseases 198
9. Oncologic Diseases. . . . . . . . . . . . . . . . . . . . . .243
10. Fluid, Acid-Base, & Electrolyte Disorders 266
11. Genitourinary & Renal Disorders 282
12. Neurologic Diseases 305
13. Geriatric Disorders. . . . . . . . . . . . 324
14. Psychiatric Disorders. . . . . . . . . . . . . 333
15. Dermatologic Disorders. . . . . . .349
16. Gynecologic, Dbstelric, & Breast Disorders. . . . . . . . . . . . . .400
17. Common Surgical Disorders. . . . . . . . . . . . . . . . . . .418
18. Common Pediatric Disorders 431
19. Selected Genetic Disorders. . . . . . . . . . . . . . . . . . .450
20. Common Disorders of the Eye 456
21. Common Disorders of the Ear, Nose, &Throat 471
22. Poisoning 481
Index 499
Tab index Back Cover
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Contributors
Brendan T. Campbell, MD
Research Fellow, Robert Wood Johnson Clinical Scholars Program,
University of Michigan Medical School, Ann Arbor
Common Surgical Disorders
Aaron E. Carroll, MD
Pediatric Resident, Department of Pediatrics, University of
Washington School of Medicine, Seattle
Common Pediatric Disorders
Harold R. Collard, MD
Chief Medical Resident, University of California, San Francisco
References
Mark D. Eisner, MD, MPH
Assistant Professor of Medicine, Division of Occupational &
Environmental Medicine and Division of Pulmonary & Critical
Care Medicine, Department of Medicine, University of California,
San Francisco
Pulmonary Diseases
Neal Fischbach, MD
Clinical Fellow, Division of Hematology and Oncology, University
of Cali fornia, San Francisco
Hematologic Diseases; Oncologic Diseases
Rebecca Ann Jackson, MD
Assistant Professor, Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of California, San Francisco;
Medical Director, Gynecologic Ambulatory Services,
San Francisco General Hospital
jacksonr@obgyn, ucsf.edu
Gynecologic, Obstetric, & Breast Disorders
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
x Essentials of Diagnosis and Treatment
Ashish K. Jha, MD
Chief Medical Resident, University of California, San Francisco; San
Francisco Veterans Affairs Medical Center
References
Jacob Johnson, MD
Resident, Department of Otolaryngology, University of California,
San Francisco
Common Disorders of the Ear, Nose, & Throat
Catherine Bree Johnston, MD, MPH
Assistant Clinical Professor of Medicine, Division of Geriatrics,
Department of Medicine, University of California, San Francisco;
Program Director, Geriatric Fellowship, San Francisco Veterans
Affairs Medical Center
Geriatric Disorders
S. Claiborne Johnston, MD, PhD
Assistant Professor, Department of Neurology, Uni versity of
California, San Francisco
Neurologic Diseases
Daniel R. Kaul, MD
Fellow, Division ofInfectiolls Diseases, University of Michigan
Medical School, Ann Arbor
Infectious Diseases
Kewchang Lee, MD
Assistant Clinical Professor of Psychiatry, University of Cali fornia,
San Francisco; Chief of Psychiatry Consultation, San Francisco
Veterans Affairs Medical Center
Psychiatric LJisorders
Joan Chia-Mei Lo, MD
Assistant Professor of Medicine, Uni versity of California, San
Francisco; Staff Physician, San Francisco General Hospital
Endocrine Disorders
Rajesh S. Mangrulkar, MD
Lecturer, Division of General Medicine, Department of Internal
Medicine, University of Michigan Health System, Ann Arbor, and
Ann Arbor Veterans Affairs Medical Center
Fluid, Acid-Base, & Electrolyte Disorders
Contributors xi
V. Raman Muthusamy, MD
Assistant Clinical Professor of Medicine, Division of
GaslToenterology, University of California, San Francisco
Gastrointestinal Diseases; Hepatobiliary Disorders
Brahmajee Nallamothu, MD, MPH
Fellow, Division of Cardiovascular Disease, University of Michigan
Health System, Ann Arbor
Cardiovascular Diseases
Kurt Robert Oelke, MD
Rheumatology Fellow, Department of Rheumatology, University of
Michigan Medical School, Ann Arbor
koel [email protected]
Rheumatologic & Autoimmune Disorders
Stephanie T. Phan, MD
Ophthalmology Resident, University of California, San Francisco
Common Disorders of the Eye
Jack Resneck, Jr., MD
Chief Resident, Department of Dermatology, University of
California, San Francisco
res neck @itsa.ucsf.edu
Dennatologic Disorders
Sanjay Saint, iVID, MPH
Assistant Professor of Medicine, Division of General Medicine,
University of Michigan Medical School; Research Scientist, Ann
Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
Common Genetic Disorders
Stephen M. Schenkel, MD, MPP
Resident, Department of Emergency Medicine, University of
Michigan Health System and St. Joseph Mercy Hospital,
Ann Arbor
Poisoning
La\\TenCe M. Tierney, Jr., MD
Professor of Medicine, University of California, San Francisco;
Associate Chief of Medical Services, Veterans Affairs Medical
Center, San Francisco, California
Pearls
+
xii Essentials of Diagnosis and Treatment
Louise C. Walter, MD
Geriatrics Fellow, University of California, San Francisco
Geriatric Disorders
Suzanne Watnick, MD
Nephrology Fellow, Robert Wood Johnson Clinical Scholar, Yale
University, Yale-New Haven Hospital, New Haven, Connecticut
suzanne. [email protected]
Genitourinary & Renal Disorders
Preface
This second edition of Essentials ofDiagnosis Treatment adds a feature
which we believe is unique in medical texts-a Clinical Pearl for each
main entity. The Pearl as it has come to be known in medical parlance
is a brief aphorism or maxim capsulizing and emphasizing some important
principle of diagnosis, treatment, or prognosis-often adorned with
intended humor and expressed in colloquial idiom. A Pearl should if
possible be "pithy" and memorable, thus expressed sometimes with
more certainty than perhaps is warranted by the facts of every case.
Some Pearls are truly unforgettable, such as, "A stroke is never a stroke
until it's had 50 of 050." One of the authors was offered this Pearl over
30 years ago by an older doctor, and what it means is that focal neurologic
deficits may be due to metabolic abnormalities-in particular,
severe hypoglycemia-and that appropriate interventions may therefore
restore normal nervous system function. While all the Pearls in this
book are not as catchy or compelling as that one, they are nonetheless
useful teaching aids and we hope the reader enjoys picking them and
looking at them. We should be grateful if our readers would send us
Pearls of their own for possible inclusion in subsequent editions-and
if any of ours seem off the point or unclear, we want to know that, too.
Our modest goal has been to provide a slim volume summarizing
the crucial points in diagnosis, differential diagnosis, and treatment of
selected diseases. One clinical reference is provided in each case as a
starting point for further study.
We want to thank our editor at LangelMcGraw-Hill, Shelley Reinharth,
fur suppurt, encuuragement, anu exhurtatiun withuut limit in the
development of this book.
Lawrence M. Tierney, Jr., MO
Sanjay Saint, MO, MPH
Mary A. Whooley, MO
San Francisco
Ann Arbor
October, 2001
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
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1
Cardiovascular Diseases
Aortic Dissection
• Essentials of Diagnosis
• Most patients between age 50 and age 70; risks include hypertension,
Marfan's syndrome, bicuspid aortic valve, coarctation of
the aorta, and pregnancy
• Type A involves the ascending aorta or arch; type B does not
• Sudden onset of chest pain with interscapular radiation in at-risk
patient
• Unequal blood pressures in upper extremities; new diastolic murmur
of aortic insufficiency occasionally seen in type A
• Chest x-ray nearly always abnormal; ECG unimpressive unless
right coronary artery compromised
• CT, transesophogeal echocardiography, MRl, or aortography usually
diagnostic
• Differential Diagnosis
• Acute myocardial infarction
• Angina pectoris
• Acute pericarditis
• Pneumothorax
• Pulmonary embolism
• Boerhaave's syndrome • Treatment
• Nitroprusside and beta-blockers to lower systolic blood pressure
to approximately 100 mm Hg, pulse to 60/min
• Emergent surgery for type A dissection; medical therapy for type
B is reasonable, with surgery or percutaneous intra-aortic stenting
reserved for high-risk patients
• Pearl
Severe hypertension in a patient appearing to be in shock is aortic dissection
until proved othenvise.
Reference
Pretre Ret al: Aortic dissection. Lancet 1997;349:1461. [PMID: 9461334]
1
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
2 Essentials of Diagnosis & Treatment
Pulmonary Stenosis
• Essentials of Diagnosis
• A congenital disorder causing symptoms only when transpulmonary
valve gradient is > 50 mm Hg
• Exertional dyspnea and chest pain due to right ventricular ischemia;
sudden death occurs in severe cases
• Jugular venous distention, parastemallift, systolic ejection murmur,
delayed and soft pulmonary component of 52
• Right ventricular hypertrophy on ECG; poststenotic dilation of
the main and left pulmonary arteries on chest x-ray
• Echo-doppler is diagnostic
• Treatment
• All patients require endocarditis prophylaxis
• Symptomatic patients with gradients> 50 mm Hg: percutaneous
balloon or surgical valvuloplasty; asymptomatic patients with
gradients> 75 mm Hg and right ventricular hypertrophy: evaluate
for treatment
• Prognosis for those with mild disease is good
+
• Differential Diagnosis
• Left ventricular failure
due to any cause
• Left-sided valvular disease
• Primary pulmonary
hypertension
• Chronic pulmonary embolism
• Sleep apnea
• Chronic obstructive
pulmonary disease
• Eisenmenger's
syndrome
• Pearl
Flushing with the murmur as described raises the issue of carcinoid
syndrome.
Reference
Gibbs JL: Interventional catheterisation. Opening up I: the ventricular outflow
tracts and great arteries. Heart 2000;83:111. [PMID: 10618351]
Chapter 1 Cardiovascular Diseases 3
Aortic Coarctation
• Essentials of Diagnosis
• Elevated blood pressure in the aortic arch and its branches with
reduced blood pressure distal to the left subclavian artery
• Lower extremity claudication or leg weakness with exertion in
young adults is characteristic
• Systolic blood pressure is higher in the arms than in the legs, but
diastolic pressure is similar compared with radial
Femoral pulses delayed and decreased, with pulsatile collaterals
in the intercostal areas; a harsh, late systolic murmur may be heard
in the back; an aortic ejection murmur suggests concomitant bicuspid
aortic valve
Electrocardiography with left ventricular hypertrophy; chest x-ray
may show rib notching inferiorly due to collaterals
• Transesophageal echo with doppler or MRI is diagnostic; angiography
confirms gradient across the coarctation
• Treatment
• Surgery is the mainstay of therapy; balloon angioplasty in selected
patients
• All patients require endocarditis prophylaxis even after correction
• Twenty-five percent of patients remain hypertensive after surgery
+
• Differential Diagnosis
• Essential hypertension
• Renal artery stenosis
• Renal parenchymal disease
• Pheochromocytoma
• Mineralocorticoid excess
• Oral contraceptive use
• Cushing's syndrome • Pearl
Hypertension in a patient with a bicuspid aortic valve raises concern
about coarctation.
Reference
Ovaert C et al: Balloon angioplasty of native coarctation: clinical outcomes and
predictors of success. J Am Coli Cardiol 2000;36;988. [PMlD: 10732899]
4 Essentials of Diagnosis & Treatment
Atrial Septal Defect
• Essentials of Diagnosis
• Patients with small defects are usually asymptomatic and have a
normal life span
• Large shunts symptomatic by age 40, including exertional dyspnea,
fatigue, and palpitations
• Paradoxical embolism may occur (ie, upper or lower extremity
thrombus embolizing to brain or extremity rather than lung), more
typically after shunt reversal
• Right ventricular lift, widened and fixed splitting of S2, and systolic
flow murmur in the pulmonary area
• Electrocardiography may show right ventricular hypertrophy and
right axis deviation (in ostium secundum defects), left anterior
hemiblock (in ostium primum defects); complete or incomplete
right bundle branch block in 95%
• Atrial fibrillation commonly complicates
• Echo-doppler with agitated saline contrast injection is diagnostic;
radionuclide angiogram or cardiac catheterization estimates
ratio of pulmonary flow to systemic flow (PF:SF) + • Differential Diagnosis
• Left ventricular failure
• Left-sided valvular disease
• Primary pulmonary
hypertension
• Chronic pulmonary
embolism
• Sleep apnea
• Chronic obstructive
pulmonary disease
• Eisenmenger's syndrome
• Pulmonary stenosis • Treatment
• Small defects do not require surgical correction
• Surgery or percutaneous closure devices indicated for patients
with PF:SF > 1.7 or even smaller PF:SF shunts if there is evidence
of right ventricular failure
• Surgery is contraindicated in patients with pulmonary hypertension
and right-to-Ieft shunting
• Pearl
Endocarditis is rare given low interatrial gradient, and endocarditis
prophylaxis is thus unnecessary.
Reference
Meisner H et al: Atrioventricular septal defect. Pediatr Cardiol 1998;19:276.
[PMJD: 9636249]
Chapter 1 Cardiovascular Diseases 5
Ventricular Septal Defect
+
• Essentials of Diagnosis
• Symptoms depend on the size of the defect and the magnitude of
the left-to-right shunt
• Many congenital ventricular septal defects close spontaneously
during childhood
• Small defects in adults are usually asymptomatic except for complicating
endocarditis
• Large defects usually associated with a loud pansystolic murmur
along the left sternal border, a systolic thrill, and a loud Pz
• Echo-doppler diagnostic; radionuclide angiogram or cardiac catheterization
quantifies the ratio of pulmonary Aow to systemic Aow
(PF:SF)
• Differential Diagnosis
• Mitral regurgitation
• Aortic stenosis
• Cardiomyopathy due to various causes
• Treatment
• Small shunts in asymptomatic patients may not require surgery
• Mild dyspnea can be treated with diuretics and preload reduction
• PF:SF shunts over 2 are repaired to prevent irreversible pulmonary
vascular disease
• Surgery if patient has developed shunt reversal (Eisenmenger's
syndrome) without fixed pulmonary hypertension
• Prophylaxis for infective endocarditis
• Pearl
The smaller the defect, the more likely that it is endocarditis.
Reference
Belli E et al: Transaortic closure of residual intramural venUicular septal defect.
Ann Thorac Surg 2000;69:1496. [PMID: 10881829]
+
6 Essentials of Diagnosis &Treatment
Patent Ductus Arteriosus
• Essentials of Diagnosis
• Caused by failure of closure of embryonic ductus arteriosus with
continuous blood flow from aorta to pulmonary artery
• Symptoms are those of left ventricular failure or pulmonary
hypertension; many complaint-free
• Widened pulse pressure, a loud S2> and a continuous, "machinery"
murmur loudest over the pulmonary area but heard posteriorly
• Echo-doppler helpful, but contrast or MR aortography is the
study of choice
• Differential Diagnosis
In patients presenting with left heart failure:
• Mitral regurgitation
• Aortic stenosis
• Ventricular septal defect
If pulmonary hypertension dominates the picture, consider:
• Primary pulmonary hypertension
• Chronic pulmonary embolism
• Eisenmenger's syndrome
• Treatment
• Pharmacologic closure in premature infants, using indomethacin
or aspirin
• Surgical or percutaneous closure in patients with large shunts or
symptoms; efficacy in the presence of moderate pulmonary hypertension
is debated
• Prophylaxis for infective endocarditis
• Pearl
Patients usually remain asymptomatic as adults if problems have not
developed by age 10.
Reference
Rao PS:Transcatheter occlusion of patent ductus arteriosus: which method to use
and which ductus Lo close. Am Hearl J 1996; 132:905. [pMID: 8831389]
Chapter 1 Cardiovascular Diseases 7
Mitral Stenosis
• Essentials of Diagnosis
• Always caused by rheumatic hean disease, but 30% of patients
have no history of that disorder
• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, even
hemoptysis-often precipitated by volume overload (pregnancy,
salt load) or tachycardia
Right ventricular lift in many; opening snap occasionally palpable
• Crisp S" increased P2, opening snap; these sounds often easier to
appreciate than the characteristic low-pitched apical diastolic
murmur
Electrocardiography shows left atrial abnormality and, commonly,
atrial fibrillation; echo confirms diagnosis, quantifies severity
• Treatment
• Heart failure symptoms may be treated with diuretics and sodium
restriction
• With atrial fibrillation, ventricular rate controlled with betablockers,
calcium channel blockers such as veraparnil, or digoxin;
long-term anticoagulation instituted with warfarin
• Valvuloplasty or valve replacement in symptomatic patients with
mitral orifice of less than 1.2 cm2; valvuloplasty preferred in noncalcified
valves
Prophylaxis for beta-hemolytic streptococcal infections until age
25 and for infective endocarditis for lifetime
+
• Differential Diagnosis
• Left ventricular failure
due to any cause
• Mitral valve prolapse
(if systolic murmur present)
• Pulmonary hypertension
due to other cause
• Left atrial myxoma
• Cor triatriatum (in patients
under 30)
• Tricuspid stenosis • Pearl
Occasional patients have hoarseness due to recurrent laryngeal nerve
compression between aorta and pulmonary artery.
Reference
Bruce CJ et al: Clinical assessment and management of mitral stenosis. Cardiol
Clin 1998;16:375. [PMID: 9742320]
8 Essentials of Diagnosis &Treatment
Mitral Regurgitation
• Essentials of Diagnosis
• Causes include rheumatic heart disease, infectious endocarditis,
mitral valve prolapse, ischemic papillary muscle dysfunction,
torn chordae tendineae
• Acute: immediate onset of symptoms of pulmonary edema
• Chronic: asymptomatic for years, then exertional dyspnea and
fatigue
• 51 usually reduced; a blowing, high-pitched pansystolic murmur
increased by finger squeeze over the apex is characteristic; 53
commonly seen in chronic regurgitation; murmur is not pansystolic
and less audible in acute
Left atrial abnormality and often left ventricular hypertrophy on
ECG; atrial fibrillation typical in chronic cases
• Echo-doppler confirms diagnosis, estimates severity
• Treatment
• Acute mitral regurgitation due to endocarditis or torn chordae
may require immediate surgical repair
Prophylaxis for infective endocarditis in chronic cases; surgical
repair for severe symptoms or for left ventricular dysfunction (eg,
ejection fraction < 55%) or for enlargement by echo
Mild to moderate symptoms can be treated with diuretics, sodium
restriction, and afterload reduction (eg, ACE inhibitors); digoxin,
beta-blockers, and calcium channel blockers control ventricular
response with atrial fibrillation, and warfarin anticoagulation
should he given
+
• Differential Diagnosis
• Aortic stenosis or sclerosis
• Tricuspid regurgitation
• Hypertrophic obstructive
cardiomyopathy
• Atrial septal defect
• Ventricul ar septal defect • Pearl
An overlooked physical sign in mitral regurgitation is a rapid up-anddown
carotid pulse.
Reference
Cooper HA et al: Treatment of chronic mitral regurgitation. Am Heart J
1998;135(6 Part 1):925. [PMlD: 9630095]
+
Chapter 1 Cardiovascular Diseases 9
Aortic Stenosis
• Essentials of Diagnosis
• Causes include congenital bicuspid valve and progressive senile
calcification of a nonnal three-leaflet valve; rheumatic fever rarely,
if ever, causes isolated aortic stenosis
• Dyspnea, angina, and syncope singly or in any combination; sudden
death in less than I% of asymptomatic patients
• Weak and delayed carotid pulses; a soft, absent, or paradoxically
split S2; a harsh diamond-shaped systolic ejection murmur to the
right of the sternum, often radiating to the neck
Electrocardiography shows left ventricular hypertrophy, and x-ray
may show calcification in the aortic valve
• Echo confirms diagnosis and estimates valve area and gradient;
cardiac catheterization confirms severity, documents concomitant
coronary atherosclerotic disease, present in 50%
• Differential Diagnosis
• Mitral regurgitation
• Hypertrophic obstructive or even dilated cardiomyopathy
• Atrial or ventricular septal defect
Syncope due to other causes, eg, ventricular tachycardia
• Treatment
• Surgery is indicated for all symptomatic patients, ideally before
heart failure develops
Asymptomatic patients with declining left ventricular function
considered for surgery if echo-doppler demonstrates a very high
aortic valve gradient (> 80 mm Hg) or severely reduced valve
areas (=:; 0.7 cm2)
• Percutaneous balloon valvuloplasty for temporary (6 months)
relief of symptoms in poor surgical candidates
• Pearl
Galliverden's phenomenon is the auscultatory finding of an aortic
stenosis murmur at both the aortic area and the apex, with no murmur
at the left lower sternal border.
Reference
Gila eM: Timing of aortic valve surgery. Heart 2000;84:211. [PMID:
10908267]
+
10 Essentials of Diagnosis & Treatment
Aortic Regurgitation
• Essentials of Diagnosis
• Causes include congenital bicuspid valve, endocarditis, rheumatic
heart disease, Marfan's syndrome, aortic dissection, ankylosing
spondylitis, reactive arthritis, and syphilis
• Acute aortic regurgitation: acute onset of pulmonary edema
• Chronic aortic regurgitation: asymptomatic until middle age, when
chest pain or symptoms of left heart failure develop
• Acute aortic regurgitation: reduced SI and an S3 along with signs
of acute pulmonary edema
• Chronic aortic regurgitation: reduced first heart sound, wide pulse
pressure, water-hammer pulse, subungual capillary pulsations
(Quincke's sign), rapid rise and fall of pulse (Corrigan's pulse),
and a diastolic murmur over a partially compressed femoral artery
(Duroziez's sign)
• Soft, high-pitched, decrescendo diastolic murmur in chronic aortic
regurgitation; occasionally, an accompanying apical low-pitched
diastolic rumble (Austin Flint murmur) in nonrheumatic patients;
in acute aortic regurgitation, the diastolic murmur can be short
• ECG shows left ventricular hypertrophy, and x-ray shows left ventricular
dilation
• Echo-doppler confirms diagnosis, estimates severity
• Differential Diagnosis
• Pulmonary hypertension with Graham SteeH murmur
• Mitral or, rarely, tricuspid stenosis
• Left ventricular failure due to other cause
Dock's murmur of left anterior descending artery stenosis
• Treatment
• Vasodilators (eg, nifedipine and ACE inhibitors) delay the progression
to valve replacement
In chronic aortic regurgitation, surgery reserved for patients with
symptoms of mild left ventricular dysfunction or enlargement on
echocardiography
• Acute regurgitation caused by aortic dissection or endocarditis
requires surgical replacement of the valve
• Pearl
The Key-Hodgkin murmur of aortic regurgitation is harsh and raspy
and caused by leaflet eventration.
Reference
Bonow RO: Chronic aortic regurgitation. Role of medical therapy and optimal
timing for surgery. Cardiol Clin 1998;16:449. [PM1D: 9742324]
+
Chapter 1 Cardiovascular Diseases 11
Tricuspid Stenosis
• Essentials of Diagnosis
• Usually rheumatic in origin; rarely, seen in carcinoid heart disease
• Almost always associated with mitral stenosis when rheumatic
• Evidence of right-sided failure: hepatomegaly, ascites, peripheral
edema, jugular venous distention with prominent (a) wave
• A diastolic rumbling murmur along the left sternal border, increasing
with inspiration
• Echo-doppler is diagnostic
• Differential Diagnosis
• Aortic regurgitation
• Mitral stenosis
• Pulmonary hypertension due to any cause with right heart failure
• Treatment
• Valve replacement in severe cases
• Balloon valvuloplasty may prove to be useful in many patients
• Pearl
Three percent ofcases of left-sided rheumatic heart disease are associated
with tricuspid stenosis.
Reference
Blaustein AS et al: Tricuspid val ve disease. Clinical evaluation, physiopathology,
and management. Cardiol Clin 1998;16:551. [PMID: 9742330]
+
12 Essentials of Diagnosis & Treatment
Tricuspid Regurgitation
• Essentials of Diagnosis
• Causes include infective endocarditis, right ventricular heart
failure, carcinoid syndrome, systemic lupus erythematosus, and
Ebstein's anomaly
• Most cases secondary to dilation of the right ventricle from leftsided
heart disease
• Edema, abdominal discomfort, anorexia; otherwise, symptoms of
associated disease
• Prominent (v) waves in jugular venous pulse; pulsatile liver,
abdominojugular reflux
• Characteristic high-pitched blowing holosystolic murmur along
the left sternal border increasing with inspiration
• Echo-doppler is diagnostic
• Differential Diagnosis
• Mitral regurgitation
• Aortic stenosis
• Pulmonary stenosis
• Atrial septal defect
• Ventricular septal defect
• Treatment
• Diuretics and dietary sodium restriction in patients with evidence
of fluid overload
• If symptoms are severe and tricuspid regurgitation is primary,
valve repair, valvuloplasty, or removal is preferable to valve replacement
• Pearl
Over 90% of apparently isolated right heart failure is caused by leftsidedfailure.
Reference
Waller BF et al: Pathology of tricuspid valve stenosis and pure tricuspid regurgitation-
Part II. Clin CardioI1995;18:167. [PMlD: 7743689]
+
Chapter 1 Cardiovascular Diseases 13
Angina Pectoris
• Essentials of Diagnosis
• Pressure-like episodic precordial chest discomfort, precipitated
by exertion or stress, relieved by rest or nitrates
• Generally caused by atherosclerotic coronary artery disease; cigarette
smoking, diabetes, hypertension, hypercholesterolemia, and
family history are established risk factors
• S4, S3, mitral murmur may occur transiently with pain
• Electrocardiography usually normal between episodes (or may
show evidence of old infarction); electrocardiography with pain
usually shows evidence of ischemia, classically ST depression
• Diagnosis from history and stress tests; confirmed and staged by
coronary arteriography
• Differential Diagnosis
• Other coronary syndromes (myocardial infarction, unstable angina,
vasospasm)
• Tietze's syndrome (costochondritis)
• Intercostal neuropathy, especially caused by herpes zoster
• Cervical radiculopathy
• Peptic ulcer disease
Esophageal spasm or reflux disease
• Cholecystitis
• Pneumothorax
Pulmonary embolism
Pneumonia
• Treatment
• Address reversible risk factors (smoking, hypertension, hypercholesterolemia,
hyperglycemia)
• Sublingual nitroglycerin as needed for individual episodes
• Ongoing treatment includes aspirin, long-acting nitrates, betablockers,
and calcium channel blockers
• Angioplasty with or without stenting considered in patients with
anatomically suitable stenoses who remain symptomatic on medical
therapy
• Bypass grafting for patients with refractory angina on medical
therapy, three-vessel disease (or two-vessel disease with proximal
left anterior descending artery disease) and decreased left
ventricular function, or left main coronary artery disease
• Pearl
Up to 20% of patients with ischemic episodes do not show electrocardiographic
changes with pain.
Reference
Lee TH et al: Evaluation of the patient with acute chest pain. N Engl J Med
2000;342: 1187. [PMTD: 10770985]
14 Essentials of Diagnosis & Treatment
Prinzmetal's Angina
• Essentials of Diagnosis
• Caused by intermittent focal spasm of an otherwise normal coronary
artery
• The chest pain resembles typical angina; often more severe and
occurs at rest
• Affects women under 50, occurs in the early morning, and typically
involves the right coronary artery
• Electrocardiography shows ST elevation, but enzyme studies are
normal
• Diagnosis can be confirmed by ergonovine challenge during cardiac
catheterization
• Treatment
• Nitrates and calcium channel blockers effective acutely
• Long-acting nitrates and calcium channel blockers are the mainstay
of chronic therapy
• Stenting in affected coronary artery (usually right) in some, but
prognosis excellent given absence of atherosclerosis
+
• Differential Diagnosis
• Typical angina pectoris
• Myocardial infarction
• Unstable angina
• Tietze's syndrome
(costochondritis)
• Cervical radiculopathy
• Peptic ulcer disease
• Esophageal spasm or reflux
disease
• Cholecystitis
• Pericarditis
• Pneumothorax
• Pulmonary embolism
• Pneumonia • Pearl
Cocaine use can lead to myocardial ischemia or infarction/rom vasospasm.
Reference
Yasue H et al: Coronary spasm: clinical features and pathogenesis. Intem Med
1997;36:760. [PMlD: 9392345]
Chapter 1 Cardiovascular Diseases 15
Unstable Angina
• Essentials of Diagnosis
• Spectrum of illness between chronic stable angina and acute myocardial
infarction
• Characterized by accelerating angina, pain at rest, or pain that is
less responsive to medications
• Usually due to atherosclerotic plaque rupture, spasm, hemorrhage,
or thrombosis
• Chest pain resembles typical angina but is more severe and lasts
longer (up to 30 minutes)
ECG may show dynamic ST depression or T wave changes during
pain but normalizes when symptoms abate; a normal ECG,
however, does not rule out unstable angina
+
• Differential Diagnosis
• Typical angina pectoris
• Myocardial infarction
• Coronary vasospasm
Aortic dissection
• Tietze's syndrome
(costochondritis)
• Cervical radiculopathy
Peptic ulcer disease
Esophageal spasm or reflux
disease
• Cholecystitis
Pericarditis
Pneumothorax
• Pulmonary embolism
Pneumonia • Treatment
• Hospitalization with bed rest, telemetry, and exclusion of myocardial
infarction
Low-dose aspirin (81-325 mg) should be given immediately on
admission and every day thereafter; intravenous heparin is of
benefit in some
Beta-blockers to keep heart rate and blood pressure in the lownormal
range
• Tn high-risk patients, glycoprotein TIh/TITa inhihitors shown to he
of benefit, especially if percutaneous intervention likely
• Nitroglycerin, either in paste or intravenously
• Cardiac catheterization and consideration of revascularization in
appropriate candidates
• Pearl
Aortic dissection should be considered in any chest pain syndrome for
which aggressive anticoagulation is being contemplated.
Reference
Ambrose JA et aI: Unstable angina: current concepts of pathogenesis and treatment.
Arch Jntem Med 2000;160:25. [pMJD: 10632302]
16 Essentials of Diagnosis & Treatment
Acute Myocardial Infarction
• Essentials of Diagnosis
• Prolonged (> 30 minutes) chest pain, associated with shonness of
breath, nausea, left arm or neck pain, and diaphoresis; can be painless
in diabetics
• S4 common; S3, mitral insufficiency on occasion
• Cardiogenic shock, ventricular arrhythmias may complicate
• Electrocardiography shows ST elevation or depression, T wave
inversion, or evolving Q waves; however, can be normal or unchanged
in up to 10%
• Elevated cardiac enzymes (troponin, CKMB)
• Regional wall motion changes by echo
• Non-Q wave infarct may mean additional jeopardized myocardium
• Treatment
• Monitoring, aspirin, and analgesia for all; heparin for most
• Reperfusion by thrombolysis or angioplasty in selected patients
with either ST segment elevation or new left bundle branch block
onECG
• Glycoprotein Ilb/Ina inhibitors considered in non-Q wave infarcts
• Beta-blockers for heart rate and blood pressure control, and survival
advantage when given chronically
Nitroglycerin for recurrent ischemic pain; also useful for relieving
pulmonary congestion and reducing blood pressure
ACE inhihitor may confer survival henefit
+
• Differential Diagnosis
• Stable or unstable angina
• Tietze's syndrome
(costochondritis)
• Aortic dissection
• Cervical radiculopathy
• Carpal tunnel syndrome
• Esophageal spasm or reflux
• Pulmonary embolism
• Cholecystitis
• Pericarditis
• Pneumothorax
• Pneumonia • Pearl
Monitoring for prompt treatment ofventricularfibrillation remains the
most cost-effective intervention to prolong life.
Reference
Maynard S et al: Management of acute coronary syndromes. BMJ 2000;321 :220.
[PMJD: 10903658]
+
Chapter 1 Cardiovascular Diseases 17
Atrial Fibrillation
• Essentials of Diagnosis
• The most common chronic arrhythmia
• Causes include mitral valve disease, hypertensive and ischemic
heart disease, dilated cardiomyopathy, alcohol use, hyperthyroidism,
pericarditis, cardiac surgery; many are idiopathic ("lone"
atrial fibrillation)
• Complications include precipitation of cardiac failure, arterial
embolization
• Palpitations, shortness of breath, chest pain common
• Irregularly irregular heartbeat, variable intensity Sl' occasional
S,; S4 absent in all
• Electrocardiography shows ventricular rate of 80-l70/min in
untreated patients; if associated with an accessory pathway, the
ventricular rate can be> 200/min with wide QRS and antegrade
conduction through the pathway
• Differential Diagnosis
• Multifocal atrial tachycardia
• Atrial flutter or tachycardia with variable block
• Sinus arrhythmia
• Normal sinus rhythm with multiple premature contractions
• Treatment
• Control ventricular response with digoxin, beta-blocker, calcium
channel blocker-choice depending upon contractile state ofleft
ventricle
• Cardioversion with countershock in unstable patients with acute
atrial fibrillation; elective countershock or antiarrhythmic agents
(eg, ibutilide, procainamide, amiodarone, sotalol) in stable patients
once a left atrial thrombus has been ruled out or effectively treated
• Chronic warfarin or aspirin in aJi patients not cardioverted
• With elective cardioversion, anticoagulation for 4 weeks prior to
and 4 weeks after the procedure unless transesophageal echocardiography
excludes a left atrial thrombus
• Pearl
Atrialfibrillation is a relatively uncommon rhythm in acute myocardial
infarction and implies the presence ofpericarditis.
Reference
Prystowsky EN: Management of atrial fibrillation: therapeutic options and clinical
decisions. Am J Cardiol 2000;85:30. [PMID: 10822035]
+
18 Essentials of Diagnosis & Treatment
Atrial Flutter
• Essentials of Diagnosis
• Especially common in COPD; also seen in dilated cardiomyopathy,
especially in alcoholics
• Atrial rate between 250 and 350 beats/min with every second,
third, or fourth impulse conducted by the ventricle
• Patients may be asymptomatic, complain of palpitations, or have
evidence of congestive hean failure
• Flutter (a) waves visible in the neck in occasional patients
• Electrocardiography shows "sawtooth" P waves in VI and the inferior
leads; ventricular response usually regular; less commonly,
irregular due to variable atrioventricular block
• Differential Diagnosis
With regular ventricular rate:
• Automatic atrial tachycardia
• Atrioventricular nodal reentry tachycardia
• Sinus tachycardia
With irregular ventricular rate:
• Atrial fibrillation
• Multifocal atrial tachycardia
• Treatment
• Often spontaneously converts to atrial fibrillation
• Electrical cardioversion is reliable and safe
• Conversion may also be achieved by drugs (eg, ibutilide)
• Risk of embolization is lower than for atrial fibrillation, but anticoagulation
still recommended
• Amiodarone in patients with chronic atrial flutter
• Consider radiofrequency ablation in patients with chronic atrial
flutter refractory to medical therapy
• Pearl
A regular heart rate of 140-150 in a patient with COPD isjhltter until
proved otherwise.
Reference
Campbell, RW: Atrial flutter. Eur Heart J 1998;l9(Suppl E):E37. [PMlO:
9717023]
+
Chapter 1 Cardiovascular Diseases 19
Multifocal Atrial Tachycardia
• Essentials of Diagnosis
• Classically seen in patients with severe COPD; electrolyte abnormalities
(especially hypomagnesemia or hypokalemia) may also
be responsible
• Symptoms those of the underlying disorder, but some may complain
of palpitations
• Irregularly irregular hean rate
• Electrocardiography shows at least three different P wave morphologies
with varying P-P intervals
• Ventricular rate usually between 100 and 140 beats/min; if less
than 100, rhythm is wandering atrial pacemaker
• Differential Diagnosis
• Normal sinus rhythm with multiple premature atrial contractions
• Atrial fibrillation
• Atrial flutter with variable block
• Reentry tachycardia with variable block
• Treatment
• Treatment of the underlying disorder is most important
• Verapamil particularly useful for rate control; digitalis ineffective
• Intravenous magnesium and potassium administered slowly may
convert some patients to sinus rhythm even if serum levels are
within normal range
• Medications causing atrial irritability, such as theophylline, should
be avoided
• Atrioventricular nodal ablation with permanent pacing is used in
rare cases that are refractory to pharmacologic therapy
• Pearl
Irregularly irregular rhythm in COPD is more commonly multifocal
atrial tachycardia than atrial fibrillation.
Reference
McCord] et al: Multifocal atrial tachycardia. Chest 1998;113:203. [PMID:
9440591]
+
20 Essentials of Diagnosis & Treatment
Paroxysmal Supraventricular Tachycardia (PSVT)
• Essentials of Diagnosis
• A group of arrhythmias including supraventricular reentrant tachycardia
(over 90% of cases), automatic atrial tachycardia, and junctional
tachycardia
• Attacks usually begin and end abruptly, last seconds to hours
• Patients often asymptomatic but occasionally complain of palpitations,
mild shortness of breath, or chest pain
• Electrocardiography between attacks nonnal unless the patient
has WolfF-Parkinson-White syndrome
• Unless aberrant conduction occurs, the QRS complexes are regular
and narrow; the location of the P wave helps determine the
origin of the PSVT
• Electrophysiologic study establishes the exact diagnosis
• Differential Diagnosis
NaP:
• Atrioventricular nodal reentry tachycardia
Slwrt RP:
• Atrioventricular reentrant tachycardia
• Intra-atrial reentry tachycardia
Long RP:
• Atrial tachycardia
• Some atrioventricular nodal reentry tachycardia
• Pennanent junctional reciprocating tachycardia
• Treatment
• Many attacks resolve spontaneously; if not, first try vagal maneuvers
such as carotid sinus massage
• Prevention of frequent attacks can be achieved by digoxin, calcium
channel blockers, beta-blockers, or antiarrhythmics such as
procainamide or sotalol; many believe electrophysiologic study
and ahlation of the ahnormal reentrant circuit or focus, when
available, is the treatment of choice (> 90% success rate)
• Pearl
In Q-wave infarct computer readouts with short PR intervals, look
carefully for a delta wave.
Reference
Basta M et al: CUlTent role of pharmacologic therapy for patients witll paroxysmal
supraventricular tachycardia. Cardiol Clin 1997;15:587. [PMlD: 9403162]
+
Chapter 1 Cardiovascular Diseases 21
Ventricular Tachycardia
• Essentials of Diagnosis
• Three or more consecutive premature ventricular beats; nonsustained
(lasting < 30 seconds) or sustained
• Mechanisms are reentry or automatic focus; may occur spontaneously
or with myocardial infarction
• Other causes include acute or chronic ischemia, cardiomyopathy,
and drugs (eg, antiarrhythmics)
• Most patients symptomatic; syncope, palpitations, shortness of
breath, and chest pain are common
• SI of variable intensity; S3 present
• Electrocardiography shows a regular, wide-complex tachycardia
(usually between 140 and 220 beats/min); between attacks, the
ECG often shows evidence of prior myocardial infarction
• Differential Diagnosis
• Any cause of supraventricular tachycardia with aberrant conduction
(but a history of myocardial infarction or low ejection fraction
indicates ventricular tachycardia until proved otherwise)
• Atrial flutter with aberrant conduction
• Treatment
• Depends upon whether the patient is stable or unstable
• If stable: intravenous lidocaine, procainamide, or amiodarone can
be used initially
If unstable (hypotension, congestive heart failure, or angina):
immediate synchronized cardioversion
For chronic, recurrent, sustained ventricular tachycardia, either
automatic implantable cardiac defibrillator placement or suppressive
treatment guided by electrophysiologic studies should
be considered
• Treatment of recurrent asymptomatic, nonsustained ventricular
tachycardia is conLToversial; in a patient with ischemic heart
disease and a low left ventricular ejection fraction «35%), an
implantable cardiac defibrillator or electro physiologic study
should be considered
• Pearl
The first 60 beats may be slightly irregular and misdiagnosed as atrial
fibrillation with aberrant conduction.
Reference
Doherty JU et al: Ventricular arrhythmias. Preventing sudden death with drugs
and reD devices. Geriatrics 2000;55:26. [PMID: 10953684]
+
22 Essentials of Diagnosis & Treatment
Sudden Cardiac Death
• Essentials of Diagnosis
• Death in a well patient within 1 hour of symptom onset
• Sudden death can be due to cardiac or noncardiac disease
• Most common cause (over 80% of cases) is ventricular fibrillation
or tachycardia in the setting of coronary artery disease
• Ventricular fibrillation is almost always the terminal rhythm
• Differential Diagnosis
Noncardiac causes ofsudden death:
Pulmonary embolism
Asthma
Aortic dissection
Ruptured aortic aneurysm
Intracranial hemorrhage
Tension pneumothorax
Anaphylaxis
• Treatment
• Tf sudden cardiac death occurs in the setting of acute myocardial
infarction, long-term management is no different from that of
other patients with myocardial infarction
• In the absence of myocardial infarction, the recurrence rate of sudden
cardiac death in ischemic disease is 50% in 2 years; therefore,
an aggressive approach (cardiac catheterization, revascularization)
to prevent another event is warranted
• Electrolyte abnormalities, digitalis toxicity, pacemaker malfunction
can be the cause and are treated accordingly
Without an obvious cause, echocardiography and cardiac catheterization
indicated; electrophysiologic studies in patients with normal
echo-doppler and coronary anatomy
• A transvenous cardiac defibrillator is strongly considered in all
patients surviving an episode of sudden cardiac death secondary
to ventricular fibrillation or tachycardia without a transient or
reversible cause
• Pearl
In sudden cardiac death in adults, ifmyocardial infarction is ruled out,
the prognosis is paradoxically worse than if ruled in-it suggests that
active ischemia is still ongoing, and urgent cardiac catheterization is
obligatory.
Reference
Goldberger JJ: Treatment and prevention of sudden cardiac death: effect of
recent clinicallrials. Arch Intern Med 1999; 159: 128 I. [PMlD: 10386504]
+
Chapter 1 Cardiovascular Diseases 23
Atrioventricular Block
• Essentials of Diagnosis
• First-degree block: delayed conduction at the level of the atrioventricular
node; PR interval> 0.20 s
• Second-degree block; Mobitz I-progressive prolongation of the
PR interval and decreasing R-R interval prior to a blocked sinus
impulse; Mobitz II shows fixed PR intervals before a beat is
dropped
• Third-degree block is due to complete block at or below the node;
P waves and QRS complexes occur independently of one another,
both at fixed rates
• Clinical manifestations of third-degree block include chest pain,
syncope, and shortness of breath; cannon (aJ waves in neck veins;
first heart sound varies in intensity
• Differential Diagnosis
Causes offirst-degree and Mobitz 1 atrioventricular block:
• Increased vagal tone
• Drugs that prolong atrioventricular conduction
Causes ofMobitz 11 and third-de~ree atrioventricular block:
• Chronic degenerative conduction system disease (Lev's and
Lenegre's syndromes)
• Acute myocardial infarction; inferior myocardial infarction causes
complete block at the node, anterior myocardial infarction below it
• Acute myocarditis (eg, Lyme disease, viral myocarditis)
• Digitalis toxicity
• Congenital
• Treatment
• In symptomatic patients with Mobitz I, permanent pacing
• For those with Mobitz II or infranodal third-degree atrioventricular
block, permanent pacing unless a reversible cause (eg, drug
toxicity, inferior myocardial infarction, Lyme disease) is present
• Pearl
A "circus ofatrial sounds" may be created by atrial contractions at different
rates than ventricular, eg, in complete heart block.
Reference
Hayes DL: Evolving indications for permanent pacing. Am J Cardiol 1999;
83(5B):16ID. [PMID: 10089860]
+
24 Essentials of Diagnosis & Treatment
Congestive Heart Failure
• Essentials of Diagnosis
• Two pathophysiologic categories: systolic dysfunction and diastolic
dysfunction
• Systolic: the ability to pump blood is compromised; ejection fraction
is decreased; causes include coronary artery disease, dilated
cardiomyopathy, myocarditis, "burned-out" hypertensive heart
disease, and valvular heart disease
• Diastolic heart unable to relax and allow adequate diastolic filling;
normal ejection fraction; causes include ischemia, hypertension
with left ventricular hypertrophy, aortic stenosis, hypertrophic
cardiomyopathy, restrictive cardiomyopathy, and small vessel
disease (eg, diabetes mellitus)
• Evidence of both common, but up to 20% of patients will have
isolated diastolic dysfunction
• Symptoms and signs can result from left-sided failure, right-sided
failure, or both
• Left ventricular failure: exertional dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, pulsus alternans, rales, gallop rhythm;
pulmonary venous congestion on chest x-ray
• Right ventricular failure: fatigue, malaise, elevated venous pressure,
hepatomegaly, and dependent edema
• Diagnosis confirmed by echo or pulmonary capillary wedge measurement
• Differential Diagnosis
• Pericardial disease
• Nephrosis or cirrhosis
• Hypothyroidism
• Treatment
• Systolic dysfunction: vasodilators (ACE inhibitors or combination
of hydralazine and isosorhide diniLTate), heta-hlockers, spironolactone,
and low-sodium diet; for symptoms, use diuretics and
digoxin; anticoagulation advocated by many in high-risk patients
• Diastolic dysfunction: a negative inotrope (beta-blocker or calcium
channel blocker), low-sodium diet, and diuretics for symptoms
• Pearl
Ninety-five percent ofright heart failure is caused by left heart failure.
Reference
Watson RD et aJ: ABC of heart failure. Clinical features and complications.
BMJ;2000;320:236. [PMlD: 10642237]
+
Chapter 1 Cardiovascular Diseases 25
Myocarditis
• Essentials of Diagnosis
• Focal or diffuse inflammation of the myocardium due to various
infections, toxins, drugs, or immunologic reactions; viral infection,
particularly with coxsackievimses, is the most common cause
• Other infectious causes include Rocky mountain spotted fever,
Qfever, Chagas' disease, Lyme disease, AIDS, trichinosis, toxoplasmosis,
and acute rheumatic fever
• Symptoms include fever, fatigue, palpitations, chest pain, or
symptoms of congestive heart failure, often following an upper
respiratory tract infection
Electrocardiography may reveal ST- T wave changes, conduction
blocks
• Echocardiography shows diffusely depressed left ventricular function
and enlargement
• Routine myocardial biopsy usually not recommended since inflammatory
changes are often focal and nonspecific
• Differential Diagnosis
• Acute myocardial ischemia or infarction due to coronary artery
disease
• Pneumonia
• Congestive heart failure due to other causes
• Treatment
• Bed rest
• Specific antimicrobial treatment if an infectious agent can be
identified
• Immunosuppressive therapy is controversial
• Appropriate treatment ofthe systolic dysfunction that may develop:
vasodilators (ACE inhibitors or combination of hydralazine and
isosorbide dinitrate), beta-blockers, spironolactone, digoxin, lowsodium
diet, and diuretics
• Pearl
"Rule ofthirds" for patients with viral myocarditis: one-third retum to
normal, one-third have stable left ventricular dysfunction, and onethird
have a rapidly deteriorating course.
Reference
Pisani B et al: Inflammatory myocardial diseases and cardiomyopathies. Am J
Med 1997;102:459. [PMID: 9217643]
+
26 Essentials of Diagnosis & Treatment
Dilated Cardiomyopathy
• Essentials of Diagnosis
• A cause of systolic dysfunction, this represents a group of disorders
that lead to congestive heart failure
• Symptoms and signs of congestive heart failure: exertional dyspnea,
cough, fatigue, paroxysmal nocturnal dyspnea, cardiac
enlargement, rales, gallop rhythm, elevated venous pressure,
hepatomegaly, and dependent edema
• Electrocardiography may show nonspecific repolarization abnormalities
and atrial or ventricular ectopy but is not diagnostic
• Echocardiography reveals depressed contractile function and
cardiomegaly
• Cardiac catheterization useful to exclude ischemia as a cause
• Differential Diagnosis
Causes ofdilated cardiomyopathy:
• Alcoholism
• Post viral myocarditis
• Sarcoidosis
• Postpartum
• Doxorubicin toxicity
• Endocrinopathies (thyroid disease, acromegaly, pheochromocytoma)
• Hemochromatosis
• Idiopathic
• Treatment
• Treat the underlying disorder when identifiable
• Abstention from alcohol
• Routine management of systolic dysfunction, including with vasodilators
(ACE inhibitors or a combination of hydralazine and isosorbide
dinitrate), beta-blockers, spironolactone, and low-sodium
diet; digoxin and diuretics for symptoms
• Pearl
Causes of death: one-third pump failure, one-third arrhythmia. onethird
stroke, of which the latter is most preventable.
Reference
Elliott P: Cardiomyopathy. Diagnosis and management of dilated cardiomyopathy.
Heart 2000;84:106. [PMID: 20321212]
Chapter 1 Cardiovascular Diseases 27
+
Hypertrophic Obstructive Cardiomyopathy (HOCM)
• Essentials of Diagnosis
• Asymmetric myocardial hypertrophy causing dynamic obstruction
to left ventricular outflow below the aortic valve
• Sporadic or dominantly inherited
• Obstruction is worsened by increasing left ventricular contractility
or decreasing filling
• Symptoms are dyspnea, chest pain, and syncope; a subgroup of
younger patients is at high risk for sudden cardiac death (l% per
year), especially with exercise
• Sustained, bifid (rarely trifid) apical impulse, S4
• Electrocardiography shows exaggerated septal Qwaves suggestive
of myocardial infarction; supraventricular and ventricular
arrhythmias may also be seen
• Echocardiography with hypertrophy, evidence of dynamic obstruction
from abnormal systolic motion of the anterior mitral
valve leaflet
• Differential Diagnosis
• Hypertensive heart disease
• Restrictive cardiomyopathy (eg, amyloidosis)
• Aortic stenosis
• Ischemic heart disease
• Athlete's heart
• Treatment
• Beta-blockers are the initial drug of choice in symptomatic patients,
especially those with evidence of dynamic obstruction
• Calcium channel blockers may also be useful
• Otherwise, surgical myectomy, percutaneous transcoronary septal
reduction with alcohol, or dual-chamber pacing are considered;
automatic implantable cardiac defibrillator, amiodarone in patients
at high risk for sudden death is controversial
• Natural history is unpredictable; sports requiring high cardiac
output should be discouraged
• All first-degree relatives evaluated with echocardiography
• Prophylaxis for infective endocarditis is required
• Pearl
Hypertrophic cardiomyopathy is the pathologicfeature mostfrequently
associated with sudden death in athletes.
Reference
Spirito P et a1: Perspectives on the role of new treatment strategies in hypertrophic
obstructive cardiomyopathy. ] Am Coli Cardiol 1999;33: 1071.
[PMTD: 10091838]
+
28 Essentials of Diagnosis & Treatment
Restrictive Cardiomyopathy
• Essentials of Diagnosis
• Characterized by impaired diastolic filling with preserved left
ventricu lar function
• Causes include amyloidosis, sarcoidosis, hemochromatosis, scleroderma,
carcinoid syndrome, endomyocardial fibrosis, and postradiation
or postsurgical fibrosis
• Clinical manifestations are those of the underlying disorder; congestive
heart failure with right-sided symptoms and signs usually
predominates
Electrocardiography may show low voltage and nonspecific ST- T
wave abnormalities; supraventricular and ventricular arrhythmias
may also be seen
• Echo-doppler shows increased wall thickness with preserved
contractile function and mitral and tricuspid inflow velocity patterns
consistent with impaired diastolic filling
• Differential Diagnosis
• Constrictive pericarditis
• Hypertensive heart disease
• Hypertrophic obstructive cardiomyopathy
• Aortic stenosis
• Ischemic heart disease
• Treatment
• Sodium restriction and diuretic therapy for patients with evidence
of fluid overload; diuresis must be cautious, as volume depletion
may worsen this disorder
• Digitalis is not indicated unless systolic function becomes impaired
or atrial fi brillation occurs
• Treatment of underlying disease causing the restriction if possible
• Pearl
Hemochromatosis is characterized by diagnostic T2-weighted images
of the heart and other involved organs; one-third of patients have
whiter right upper quadrants on plain chest films.
Reference
Kushwasha 55 et al: Restrictive cardiomyopathy. N En1o ] J Med 1997;336:267.
[PMID: 8995091]
+
Chapter 1 Cardiovascular Diseases 29
Acute Rheumatic Fever
• Essentials of Diagnosis
• A systemic immune process complicating group A beta-hemolytic
streptococcal pharyngitis
• Usually affects children between the ages of 5 and 15; rare after 25
• Occurs 1-5 weeks after throat infection
• Diagnosis based on Jones criteria (two major or one major and
two minor) and confirmation of recent streptococcal infection
• Major criteria: erythema marginatum, migratory polyarthritis,
subcutaneous nodules, carditis, and Sydenham's chorea; the latter
is the most specific, least sensitive
• Minor criteria: fever, arthralgias, elevated erythrocyte sedimentation
rate, elevated C-reactive protein, PR prolongation on ECG,
and history of rheumatic fever
• Differential Diagnosis
• Juvenile or adult rheumatoid arthritis
• Endocarditis
• Osteomyelitis
• Systemic lupus erythematosus
Lyme disease
• Disseminated gonococcal infection
• Treatment
• Bed rest until vital signs and ECG become normal
Salicylates and nonsteroidal anti-inflammatory drugs reduce fever
and joint complaints but do not affect the natural course of the disease;
rarely, corticosteroids may be used
• If streptococcal infection is still present, penicillin is indicated
Prevention of recurrent streptococcal pharyngitis in patients less
than 25 years old (a monthly injection of benzathine penicillin is
most commonly used)
• Pearl
Inappropriate tachycardia in a child with a recent sore throat suggests
rheumatic fever.
Reference
cia Silva NA el al: Rheumatic fever. Still a challenge. Rheum Dis Clin North Am
1997;23:545. [PMlD: 9287377]
+
3D Essentials of Diagnosis & Treatment
Acute Pericarditis
• Essentials of Diagnosis
• Inflammation of the pericardium due to viral infection, drugs,
myocardial infarction, autoimmune syndromes, renal failure, cardiac
surgery, trauma, or neoplasm
• Common symptoms include pleuritic chest pain radiating to the
shoulder (trapezius ridge) and dyspnea; pain improves with sitting
up and expiration
Examination may reveal fever, tachycardia, and an intermittent
friction rub; clinical manifestations of cardiac tamponade may
occur in any patient
Electrocardiography usually shows PR depression, diffuse ST
segment elevation followed by T wave inversions
• Echocardiography may reveal pericardia! effusion
• Differential Diagnosis
• Acute myocardial infarction
• Aortic dissection
• Pulmonary embolism
• Pneumothorax
• Pneumonia
• Cholecystitis
• Treatment
• Aspirin or nonsteroidal anti-inflammatory agents such as ibuprofen
or indomethacin to relieve symptoms; rarely, steroids for
recurrent cases
• Hospitalization for patients with symptoms suggestive of significant
effusions or cardiac tamponade
• Pearl
Patients with uremic pericarditis characteristically are afebrile, and
many lack ST segment elevation.
Reference
Oakley eM: Myocarditis, pericarditis and other pericardial diseases. Heart
2000;84:449. [PMlD: 10995424]
+
Chapter 1 Cardiovascular Diseases 31
Cardiac Tamponade
• Essentials of Diagnosis
• Life-threatening disorder occurring when pericardial fluid accumulates
under pressure; effusions increasing rapidly in size may
cause an elevated intrapericardial pressure (> 15 mm Hg), leading
to impaired cardiac filling and decreased cardiac output
• Common causes include metastatic malignancy, uremia, viral or
idiopathic pericarditis, and cardiac trauma; however, any cause
of pericarditis can cause tamponade
• Clinical manifestations include dyspnea, cough, tachycardia, hypotension,
pulsus paradoxus, jugular venous distention, and distant
heart sounds
• Electrocardiography usually shows low QRS voltage and occasionally
electrical alternans; chest x-ray shows an enlarged cardiac
silhouette with a "water-bottle" configuration if a large (> 250 mL)
effusion is present-which it need not be if effusion develops
rapidly
Echocardiography delineates effusion and its hemodynamic significance,
eg, atrial collapse; cardiac catheterization confirms the
diagnosis if equalization of diastolic pressures in all four chambers
occurs and there is loss of the normal y-descent
• Differential Diagnosis
• Tension pneumothorax
Right ventricular infarction
Severe left ventricular failure
• Constrictive pericarditis
• Restrictive cardiomyopathy
• Pneumonia with septic shock
• Treatment
• Immediate pericardiocentesis
• Volume expansion until pericardiocentesis is performed
• Definitive treatment for reaccumulation may require surgical
anterior and posterior pericardiectomy or percutaneous balloon
pericardiotomy
• Pearl
Pulsus paradoxus is useful only in regular rhythms.
Reference
Tsang TS: Diagnosis and management of cardiac tamponade in the era of
echocardiography. Clin Cardiol 1999;22:446. [PMID: 10410287]
+
32 Essentials of Diagnosis & Treatment
Constrictive Pericarditis
• Essentials of Diagnosis
• A thickened fibrotic pericardium impairing cardiac filling and
decreasing cardiac output
• May follow tuberculosis, cardiac surgery, radiation therapy, or
viral, uremic. or neoplastic pericarditis
• Symptoms include gradual onset of dyspnea, fatigue. weakness,
pedal edema, and abdominal swelling; right-sided heart failure
symptoms often predominate, with ascites sometimes disproportionate
to pedal edema
Physical examination reveals tachycardia, elevated jugular venous
distention with rapid y-descent, Kussmaul's sign, hepatosplenomegaly,
ascites, "pericardial knock" following S2, and peripheral
edema
• Pericardial calcification on chest film in less than half; electrocardiography
may show low QRS voltage; liver function tests
abnormal from passive congestion
• Echocardiography can demonstrate a thick pericardium and normal
left ventricular function; CT or MRl is more sensitive in
revealing pericardial pathology; cardiac catheterization demonstrates
dip-and-plateau pattern to left and right ventricular diastolic
pressure tracings with a prominent y-descent (in contrast to
restrictive cardiomyopathy)
• Differential Diagnosis
• Cardiac tamponade
• Right ventricular infarction
• Restrictive cardiomyopathy
• Cirrhosis with ascites (most common misdiagnosis)
• Treatment
• Acute treatment usually includes gentle diuresis
• Definitive therapy is surgical stripping of the pericardium
• Evaluation for tuberculosis
• Pearl
Constriction should be excluded in a patient with new onset ascites felt
due to cirrhosis.
Reference
Myers RB et al: Constrictive pericarditis: clinical and pathophysiologic characteristics.
Am Heart] 1999;138(2 Part 1):219. [PMID: 10426832]
+
Chapter 1 Cardiovascular Diseases 33
Cor Pulmonale
• Essentials of Diagnosis
• Heart failure resulting from pulmonary disease
• Most commonly due to COPD; other causes include pulmonary
fibrosis, pneumoconioses, recurrent pulmonary emboli, primary
pulmonary hypertension, sleep apnea, and kyphoscoliosis
• Clinical manifestations are due to both the underlying pulmonary
disease and the right ventricular failure
• Chest x-ray reveals an enlarged right ventricle and pulmonary
artery; electrocardiography may show right axis deviation, right
ventricular hypertrophy, and tall, peaked P waves (P pulmonale)
in the face of low QRS voltage
• Pulmonary function tests usually confirm the presence of underlying
lung disease, and echocardiography will show right ventricular
dilation but normal left ventricular function and elevated
right-ventricular systolic pressures
• Differential Diagnosis
Other causes ofright ventricular failure:
• Left ventricular failure (due to any cause)
• Pulmonary stenosis
• Left-to-right shunt causing Eisenmenger's syndrome
• Treatment
• Treatment is primarily directed at the pulmonary process causing
the right heart failure (eg, oxygen if hypoxia is present)
• In frank right ventricular failure, include salt restriction, diuretics,
and oxygen
• For primary pulmonary hypertension, cautious use of vasodilators
(calcium channel blockers) or continuous infusion prostacyclin
may benefit some patients
• Pearl
Oxygen is the furosemide ofthe right ventricle.
Reference
Auger WR: Pulmonary hypertension and cor pulmonale. CUff Opin Pulm Med
1995; 1:303. [PMlD: 9363069]
+
34 Essentials of Diagnosis & Treatment
Hypertension
• Essentials of Diagnosis
• In most patients (95% of cases), no cause can be found
• Chronic elevation in blood pressure (> 140/90 mm Hg) occurs in
15% of white adults and 30% of black adults in the United States;
onset usually between ages 20 and 55
• The pathogenesis is multifactorial: a combination of environmental,
dietary, genetic, and neurohormonal factors all contribute
• Most patients are asymptomatic; some, however, complain of
headache, epistaxis, or blurred vision if hypertension is severe
• Most diagnostic study abnormalities are referable to "target organ"
damage: heart, kidney, brain, retina, and peripheral arteries
• Differential Diagnosis
Secondary causes ofhypertension:
• Coarctation of the aorta
• Renal insufficiency
• Renal artery stenosis
• Pheochromocytoma
• Cushing's syndrome
• Primary hyperaldosteronism
• Chronic use of oral contraceptive pills or alcohol
• Treatment
• Decrease blood pressure with a single agent (if possible) while
minimizing side effects
• Many recommend diuretics and beta-blockers as initial therapy,
but considerable latitude is allowed for individual patients
Other agents useful either alone or in combination include ACE
inhibitors, angiotensin 11 receptor blockers, and calcium channel
blockers; <XI-blockers are considered second-line agents
• If hypertension is unresponsive to medical treatment, evaluate for
secondary causes
• Pearl
A disease without a pearl-30 million Americans have it, and no clinicalfeantre
is characteristic, either symptomatically or on examination.
Reference
Carretero OA et aJ: Essential hypertension. Part I: definition and etiology. Circulation
2000; 101 :3295. [PMID: 10645931]
+
Chapter 1 Cardiovascular Diseases 35
Deep Venous Thrombosis
• Essentials of Diagnosis
• Dull pain or tight feeling in the calf or thigh
• Up to half of patients are asymptomatic in the early stages
• Increased risk: congestive heart failure, recent major surgery, neoplasia,
oral contraceptive use by smokers, prolonged inactivity,
varicose veins, hypercoagulable states (eg, protein C deficiency,
nephrotic syndrome)
Physical signs unreliable
• Doppler ultrasound and impedance plethysmography are initial
tests of choice (less sensitive in asymptomatic patients); venography
is definitive
Pulmonary thromboembolism, especially with proximal, abovethe-
knee deep vein thrombosis
• Differential Diagnosis
• Calf strain or contusion
• Cellulitis
• Ruptured Baker cyst
• Lymphatic obstruction
• Congestive heart failure, especially right-sided
• Treatment
• Anticoagulation with intravenous heparin (goal PTT twice normal)
for 5 days followed by oral warfarin for 3-6 months; thrombolytics
in acute phlebitis may prevent valvular damage and
postphlebitic syndrome
• Subcutaneous low-molecular-weight heparin may be substituted
for intravenous heparin
NSAlDs for associated pain and swelling
For idiopathic and recurrent cases, hypercoagulable conditions
should be considered, although factor V Leiden should be sought
on a first episode without risk factors in patients of European
ethnicity
Postphlebitic syndrome (chronic venous insufficiency) is common
following an episode of deep venous thrombosis and should be
treated with graduated compression stockings, local skin care, and,
in many, chronic warfarin administration
• Pearl
The left If)wer extremity is 1 cm greater in circumference that the right
in 90% ofthe population at any point ofmeasurement.
Reference
Gorman WP et al: ABC of arterial and venous disease. Swollen lower limb-1:
general assessment and deep vein thrombosis. BMJ 2000;320:1453. [PMlD:
10837054]
+
36 Essentials of Diagnosis & Treatment
Atrial Myxoma
• Essentials of Diagnosis
• Most common cardiac tumor, usually originating in the interatrial
septum, with 80% growing into the left atrium; 5-10% bilateral
• Symptoms fall into one of three categories: (I) systemic-fever,
malaise, weight loss; (2) obstructive-positional dyspnea and
syncope; and (3) embolic-acute vascular or neurologic deficit
• Diastolic "tumor plop" or mitral stenosis-like murmur; signs of
congestive heart failure and systemic embolization in many
• Episodic pulmonary edema, classically when patient assumes an
upright position
• Leukocytosis, anemia, accelerated erythrocyte sedimentation rate
• MRl or echocardiogram demonstrates tumor
• Differential Diagnosis
• Subacute infective endocarditis
• Lymphoma
• Autoimmune disease
• Mitral stenosis
• Cor triatriatum
• Parachute mitral valve
• Other causes of congestive heart failure
• Treatment
• Surgery usually curative (recurrence rate is approximately 5%)
• Pearl
The diagnosis may be made by retrieval of embolic material by Fogarty
catheter.
Reference
Reynen K: Cardiac myxomas. NEngl J Med 1995;333:1610. [PMlD: 7477198]
2
Pulmonary Diseases
Acute Respiratory Distress Syndrome (ARDS)
• Essentials of Diagnosis
• Rapid onset of dyspnea and respiratory distress, commonly in setting
of trauma, shock, or sepsis
• Tachypnea, fever; crackles or rhonchi by auscultation
• Arterial hypoxemia refTactory to supplemental oxygen; hypercapnia
and respiratory acidosis in impending respiratory failure
• Diffuse alveolar and interstitial infiltrates by radiography, often
sparing costophrenic angles
• Normal pulmonary capillary wedge pressure
• Acute lung injury defined by a Pao2/Flo2 ratio < 300;
ARDS is defined by Pao2/Floz ratio < 200
• Differential Diagnosis
• Cardiogenic pulmonary edema
• Primary pneumonia due to any cause
• Diffuse alveolar hemorrhage
• Bronchiolitis obliterans with organizing pneumonia
• Treatment
• Mechanical ventilation with supplemental oxygen; positive endexpiratory
pressure often required
• Low tidal volume ventilation, using 6 mLlkg predicted body
weight, may reduce mortality but very uncomfortable
• Supportive therapy including adequate nutrition, vigilance for
other organ dysfunction, and prevention of nosocomial complications
(eg, catheter-related infection, venous thromboembolism)
• Mortality rate is 40-60%
• Pearl
When in doubt, run the patient dry; it works in both cardiogenic and
noncardiogenic pulmonary edema.
Reference
Ware LB et al: The acute respiratory distress syndrome. N Engl J Med 2000;
342:1334. [PMID: 10793167]
37
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
38 Essentials of Diagnosis & Treatment
Pleural Effusion
• Essentials of Diagnosis
• Many asymptomatic; pleuritic chest pain, dyspnea in some
• Decreased breath sounds and percussive dullness; bronchial
breathing above effusion
• Layering on decubitus chest x-rays; ultrasonography occasionally
required for confirmation
• Exudative effusion commonly due to malignancy, infection, autoimmune
disease, pulmonary embolism, asbestosis
• Transudative effusion caused by congestive heart failure, cirrhosis
with ascites, nephrotic syndrome, hypothyroidism
• Exudative effusions have at least one of the following: (I) pleural
fluid protein to serum protein ratio> 0.5; (2) pleural fluid LDH to
serum LDH ratio> 0.6; or (3) pleural fluid LDH > two-thirds the
upper limit of normal serum LDH
• Markedly reduced glucose in empyema, rheumatoid effusion
• Differential Diagnosis
• Atelectasis
• Lobar consolidation
• Chronic pleural thickening
• Subdiaphragmatic process
• Treatment
• Diagnostic thoracentesis for evaluating cause, with pleural fluid
glucose, protein, red and white cells counts, LDH, and relevant
cultures
• Therapy guided by suspected cause
• Pleural biopsy indicated in selected cases for diagnostic purposes
(eg, tuberculosis, mesothelioma)
• Bleomycin, tetracycline, and talc are the most effective sclerosing
agents for malignant pleural effusion
• Pearl
Amesotheliocytosis in an exudative pleural effusion implies tuberculosis
until proved o/he/wise.
Reference
Light RW: Pleural effusions. Med Clin North Am 1977;61 1339. [pMTD: 21999]
Chapler 2 Pulmonary Diseases 39
+
spontaneous Pneumothorax
• Essentials of Diagnosis
• Primary spontaneous pneumothorax occurs in the absence of
underlying disease; secondary pneumothorax complicates preexisting
pulmonary disease (eg, asthma, COPD)
• Primary spontaneous pneumothorax occurs in tall, thin boys and
young men who smoke
• Abrupt onset of ipsilateral chest pain (sometimes referred to
shoulder or arm) and dyspnea
• Decreased breath sounds over involved hemithorax, which may
be bronchial but distant in 100% pneumothorax; hyperresonance,
tachycardia, hypotension, and mediastinal shift toward contralateral
side if tension is present
• Chest x-ray diagnostic with retraction of lung from parietal pleura,
often best seen by end-expiratory film
• Differential Diagnosis
• Myocardial infarction
• Pulmonary emboli
• Pneumonia with empyema
• Pericarditis
• Treatment
• Assessment for cause, eg, pneumocystis pneumonia, lung cancer,
COPD
• Immediate decompression by needle thoracostomy if tension suspected
• Spontaneous pneumothoraces of less than 15% followed by serial
radiographs and observation in the hospital; pneumothoraces
greater than 15% treated by aspiration of air through small catheter
or by tube thoracostomy depending on clinical setting
• Secondary pneumothoraces (eg, due to COPD, cystic fibrosis)
usually require chest tube
• Discontinue smoking
• Risk of recurrence is high (up to 50% in those with primary spontaneous
pneumothorax)
• Therapy for recurrent pneumothorax includes surgical pleurodesis
or stapling of the ruptured blebs
• Pearl
Pneumotlwrax during menstruation (catamenial pneumothorax) suggests
endometriosis.
Reference
Sahn SA et al: Spontaneous pneumothorax. N Engl J Med 2000;342:868.
[PMTD: 10727592]
+
40 Essentials of Diagnosis & Treatment
Bronchiolitis Obliterans With
Organizing Pneumonia (BOOP)
• Essentials of Diagnosis
• Bronchiolitis obliterans in adults-also called cryptogenic organizing
pneumonia-may follow infections (eg, mycoplasma,
viral infection), may be due to toxic fume inhalation or associated
with connective tissue disease or organ transplantation, may complicate
local lung lesions, or may be idiopathic
• Usually characterized by abrupt onset of flu-like symptoms,
including dry cough, dyspnea, fever, and weight loss
• Dry crackles and wheezing by auscultation; clubbing rare
• Restrictive abnormalities with pulmonary function studies; hypoxemia
• Chest radiograph typically shows patchy alveolar infiltrates
bilaterally
• Open or thoracoscopic lung biopsy necessary for precise diagnosis
• Differential Diagnosis
• Idiopathic pulmonary fibrosis
• AIDS-related lung infections
• Congestive heart failure
• Mycobacterial or fungal infection
• Severe pneumonia due to bacteria, fungi, or tuberculosis
• Treatment
• Corticosteroids effective in two-thirds of cases
• Relapse common after short « 6 months) steroid courses
• Pearl
One ofthe "new" diseases; consider this when there is untimely resolution
of an infiltrate in what you thought was a community-acquired
pneumonia.
Reference
Epler GR: Bronchiolitis obliterans organizing pneumonia. Arch Intern Med
2001;161:158. [PMID: 11176728]
+
Chapter 2 Pulmonary Diseases 41
Solitary Pulmonary Nodule
• Essentials of Diagnosis
• A round or oval circumscribed lesion less than 5 em in diameter
surrounded by normal lung tissue
• Twenty-five percent of cases of bronchogenic carcinoma present
as such; the 5-year survival rate so detected is 50%
• Factors favoring benign lesion: age under 35 years, asymptomatic
status, size under 2 em, diffuse calcification, smooth margins,
and satellite lesions
Factors suggesting malignancy: age over 45 years, symptoms,
size greater than 2 em, lack of calcification, indistinct margins,
smoking history
• Skin tests, serologies, cytology rarely helpful
• Comparison with old chest radiographs essential; follow-up with
serial radiographs or CT scans often helpful; CT scan may reveal
benign-appearing calcifications
• Positron emission tomography (PET) scans are a newly emerging
diagnostic modality
• Differential Diagnosis
• Benign causes: granuloma (eg, tuberculosis or fungal infection),
arteriovenous malformation, pseudotumor, fat pad, hamartoma
• Malignant causes: primary, metastatic malignancy
• Treatment
• Options include fine-needle aspiration (FNA), surgical resection,
or radiographic follow-up over 2 years; negative FNA does not
exclude malignancy due to high false-negative rate, unless a specific
benign diagnosis is made
• Thoracic CT scan (with thin cuts through nodule) to look for
benign-appearing calcifications and evaluate mediastinum for
lymphadenopathy
• With high-risk clinical or radiographic features, surgical resection
is recommended
• In low-risk or intermediate-risk cases, close radiographic followup
may be justified
• Pearl
In calcified pulmonary nodules, the first digit of the patient's Social
Security number (always present on VA studies) suggests the specific
infectious cause.
Reference
Ost D et al: Evaluation and management of the solitary pulmonary nodule. Am
J Respir Crit Care Med 2000;162(3 Part 1):782. [PMID: 10988081]
+
42 Essentials of Diagnosis & Treatment
Asthma
• Essentials of Diagnosis
• Episodic wheezing, colds; chronic dyspnea or tightness in the
chest; can present as cough
• Some attacks triggered by cold air or exercise
• Prolonged expiratory time, wheezing; if severe, pulsus paradoxus
and cyanosis
Peripheral eosinophilia common; mucus casts, eosinophils, and
Charcot-Leyden crystals in sputum
• Obstructive pattern by spirometry supports diagnosis, though may
be nonnal between attacks
• With methacholine challenge, absence of bronchial hyperreactivity
makes diagnosis unlikely
• Differential Diagnosis
• Congestive heart failure
• Chronic obstructive pulmonary disease
• Pulmonary embolism
• Foreign body aspiration
• Pulmonary infection (eg, strongyloidiasis, aspergillosis)
• Churg-Strauss syndrome
• Treatment
• Avoidance of known precipitants, inhaled corticosteroids in persistent
asthma, inhaled bronchodilators for symptoms
In patients not well controlled on inhaled corticosteroids, longacting
inhaled beta-agonist (eg, salmeterol)
• Treatment of exacerbations: oxygen, inhaled bronchodilators
(~2 agonists or anticholinergics), systemic corticosteroids
• Leukotriene modifiers (eg, montelukast) may provide an option
for long-term therapy in mild to moderate disease
• For difficult-to-control asthma, consider exacerbating factors such
as gastroesophageal reAux disease and chronic sinusitis
• Pearl
All that wheezes is not asthma, especially over age 45.
Reference
National Asthma Education and Prevention Program: Expert Panel Report 2:
Guidelines for the diagnosis and management of asthma. National Institutes
of Health, Publication No. 97-4051, Bethesda, MD, 1997.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
+
Chapter 2 Pulmonary Diseases 43
Chronic Cough
• Essentials of Diagnosis
• One of the most common reasons for seeking medical attention
• Defined as a cough persisting for at least 4 weeks
• Chest auscultation for wheezing, nasal and oral examination for
signs of postnasal drip (eg, cobblestone appearance or erythema
of mucosa)
• Chest x-ray to exclude specific parenchymal lung diseases
• Consider spirometry before and after bronchodilator, methacholine
challenge, sinus CT scan, and 24-hour esophageal pH
monitoring
• Bronchoscopy in selected cases
• Differential Diagnosis
• Angiotensin-converting enzyme-induced cough
• Postnasal dri p
• Sinusitis
• Asthma
• Gastroesophageal reflux
• Postinfectious cough-can last 4-6 weeks
• Bronchiectasis
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Interstitial lung disease
• Sarcoidosis
• Bronchogenic carcinoma
• Treatment
• Smoking cessation
• Treat underlying condition if present
• Trial of inhaled beta-agonist (eg, albuterol)
• For postnasal drip: antihistamines (HI-antagonists or may add
nasal ipratropium hromide)
• For suspected gastroesophageal reflux disease, proton pump inhibitors
(eg, omeprazole)
• Pearl
In undiagnosed chronic cough, think ofACE inhibitors and asthma;
these are far more common than appreciated.
Reference
Philp EB: Chronic cough. Am Fam Physician 1997:56:1395. [PMID: 9337762]
+
44 Essentials of Diagnosis & Treatment
Chronic Obstructive Pulmonary Disease (COPD)
• Essentials of Diagnosis
• Primarily consisting of emphysema and chronic bronchitis; most
patients have components of both
• Acute or chronic dyspnea (emphysema) or chronic productive
cough nearly always in a heavy smoker
• Tachypnea, barrel chest, distant breath sounds, wheezes or rhonchi,
cyanosis; clubbing unusual
• Hypoxemia and hypercapnia more pronounced with chronic bronchitis
than with emphysema
• Hyperexpansion with decreased markings by chest radiography;
variable findings of bullae, thin cardiac shadow
• Airflow obstruction by spirometry; normal diffusing capacity
(OLeo) in bronchitis, reduced in emphysema
• Ventilation and perfusion well-matched in remaining lung in
emphysema, not in chronic bronchitis
• Differential Diagnosis
• Asthma
• Bronchiectasis
• Ct1-Antiprotease deficiency
• Congestive heart failure
• Recurrent pulmonary emboli
• Treatment
• Cessation of cigarette smoking is most important intervention
• Clinical trial of inhaled anticholinergic agent, eg, ipratropium
bromide
• Pneumococcal vaccination; yearly influenza vaccination
• Supplemental oxygen for hypoxic patients (Pao2 < 55 mm Hg)
reduces mortality
• For acute exacerbations, treat as acute asthma and identify underlying
precipitant; if patient has low haseline peak flow rates,
antibiotics may be beneficial
• Lung reduction surgery in selected patients with emphysema
• Pearl
The blue bloater pushes the pink puffer's wheelchair (patients with
bronchitis have better exercise tolerance than those with emphysema).
Reference
Barnes PI: Chronic obstructive pulmonary disease. N Engl I Med 2000;343:269.
[PMID: (UI: 10911010]
Chapter 2 Pulmonary Diseases 45
+
Cystic Fibrosis
• Essentials of Diagnosis
• A generalized autosomal recessive disorder of the exocrine glands
• Cough, dyspnea, recurrent pulmonary infections often due to
pseudomonas; symptoms of malabsorption, infertility
• Increased thoracic diameter, distant breath sounds, rhonchi, clubbing,
nasal polyps
• Hypoxemia; obstructive or mixed pattern by spirometry; decreased
diffusing capacity
• Sweat chloride> 60 meq/L
• Genetic testing for gene mutation can confirm diagnosis even if
sweat test is negative
• Differential Diagnosis
• Asthma
• Bronchiectasis
• Congenital emphysema (<X,-antiprotease deficiency)
• Pancreatic insufficiency
• Other causes of malabsorption
• Treatment
• Comprehensive multidisciplinary therapy required, including genetic
and occupational counseling
• Inhaled bronchodilators and chest physiotherapy
Antibiotics for recurrent airway infections guided by cultures and
sensitivities (high rate of resistant Pseudomonas aeruginosa and
Staphylococcus aureus infections seen)
Pneumococcal vaccination; yearly inAuenza vaccinations
• Recombinant human deoxyribonuclease given by aerosol has
modest benefit
• Chest physiotherapy with a variety of devices may be beneficial
• Lung transplantation is the definiti ve treatment in selected patients
• Pearl
Consider cystic fibrosis in young adults with recurrent pulmonary
irifections; formes frustes are more common than once thought.
Reference
Rubin BK: Emerging therapies for cystic fibrosis lung disease. Chest 1999;
115:1120. [PMID: 10208218]
+
46 Essentials of Diagnosis & Treatment
Foreign Body Aspiration
• Essentials of Diagnosis
• Sudden onset of cough, wheeze, and dyspnea
• Localized wheezing, hyperresonance, and diminished breath
sounds
• Localized air trapping or atelectasis on end-expiratory chest radiograph
• Differential Diagnosis
• Asthma with mucus plugging
• Bronchiolitis
• Pyogenic upper airway process (eg. Ludwig's angina, soft tissue
abscess, epiglottitis)
• Laryngospasm associated with anaphylaxis
• Bronchial compression from mass lesion
• Substernal goiter
• Tracheal cystadenoma
• Treatment
• Rronchoscopic or surgical removal of foreign body, often by rigid
bronchoscopy
• Emergency attention to airway-may require endotracheal intubation
• Pearl
An adult complaining of croup has a substernal goiter until proved
otherwise.
Reference
Reilly JS et al: Prevention and management of aerodigestive foreign body
injuries in childhood. Pediatr Clin North Am 1996;43:1403. [PMID:
8973519]
Chapter 2 Pulmonary Diseases 47
+
Allergic Bronchopulmonary Aspergillosis
• Essentials of Diagnosis
• Caused by an allergy to antigens of aspergillus species that colonize
the tracheobronchial tree
• Recurrent dyspnea, unmasked by corticosteroid withdrawal, with
history of asthma; cough productive of brownish plugs of sputum
• Physical examination as in asthma
• Peripheral eosinophilia, elevated serum IgE level, precipitating
antibody to aspergillus antigen present; positive skin hypersensitivity
to aspergillus antigen
• Infiltrate (often fleeting) and central bronchiectasis by chest radiography
• Differential Diagnosis
• Asthma
• Bronchiectasis
• Invasive aspergillosis
• Churg-Strauss syndrome
• Lamer's syndrome
• Chronic obstructive pulmonary disease
• Treatment
• Oral corticosteroids often required for several months
• Inhaled bronchodilators as for attacks of asthma
• Treatment with itraconazole (for 16 weeks) improves disease
control
• Complications include hemoptysis, severe bronchiectasis, and
pulmonary fibrosis
• Pearl
One ofthe three ways aspergillus causes disease---all different pathophysiologically.
Reference
Stevens DA et al: A randomized trial of itraconazole in allergic bronchopulmonary
aspergillosis. N Engl J Med 2000;342:756. [PMID: 10717010]
+
48 Essentials of Diagnosis & Treatment
Bronchiectasis
• Essentials of Diagnosis
• A congenital or acquired disorder affecting the large bronchi
causing permanent abnormal dilation and destruction of bronchial
walls; may be a consequence of untreated pneumonia
• Chronic cough with copious purulent three-layered sputum, hemoptysis;
weight loss, recurrent pneumonias
• Coarse, moist crackles; clubbing
• Hypoxemia; obstructive pattern by spirometry
• Chest x-rays variable, may show multiple cystic lesions at bases
in advanced cases
• High-resolution CT scan is essential for diagnosis in many cases
• Often associated with underlying systemic disorder (eg, cystic
fibrosis, hypogammaglobulinemia, IgA deficiency, common
variable immunodeficiency, primary ciliary dyskinesia), chronic
pulmonary infection (eg, tuberculosis, lung abscess), and
HIV infection
• Differential Diagnosis
• Chronic obstructive pulmonary disease
• Tuberculosis
• Chronic lung abscess
• Pneumonia due to any cause
• Treatment
• Smoking cessation
• Antibiotics selected by sputum culture and sensitivities
• Chest physiotherapy
Inhaled bronchodilators
• Surgical resection in selected patients with unresponsive localized
disease or massive hemoptysis
• Complications include cor pulmonale, amyloidosis, and secondary
visceral ahscesses (eg, hrain ahscess)
• Pearl
Paragonimiasis is the most common cause worldwide, as bronchiectasis
is the world's most common cause ofhemoptysis.
Reference
Cohen Met al: Bronchiectasis in systemic diseases. Chest 1999; 116:1063. [PMlD:
10531174]
+
Chapter 2 Pulmonary Diseases 49
Acute Tracheobronchitis
• Essentials of Diagnosis
• Poorly defined but common condition characterized by inflammation
of the trachea and bronchi
• Due to infectious agents (bacteria or viruses) or irritants (eg, dust
and smoke)
• Cough is most common symptom; purulent sputum production
and malaise common
• Variable rhonchi and wheezing; fever is often absent but may be
prominent in cases caused by Haemophilus infiuenzae
• Chest x-ray normal
• Increased incidence in smokers
• Differential Diagnosis
• Asthma
• Pneumonia
• Inhaled foreign body
• Inhalation pneumonitis
• Viral croup
• Treatment
• Symptomatic therapy with inhaled bronchodilators, cough suppressants
• Antibiotics are not recommended in all patients because they
shorten the disease course by less than I day
• Patients encouraged to stop smoking
• Pearl
Sputum culture does not help in this disorder.
Reference
Gonzales Ret aJ: Uncomplicated acute bronchitis. Ann Intell1 Med 2000;133:
981. [PlYTTD: 119400]
+
50 Essentials of Diagnosis & Treatment
Acute Bacterial Pneumonia
• Essentials of Diagnosis
• Fever, chills, cough with purulent sputum production; early pleuritic
pain, often severe, suggests pneumococcal etiology
• Tachycardia, tachypnea; bronchial breath sounds with percussive
dullness and egophony over involved lung; findings may be more
pronounced after hydration
Leukocytosis with left shift; low white count « 5000/~L) associated
with poor outcome
Patchy or lobar infiltrate by chest x-ray
• Diagnostic Gram stain or culture of sputum, blood, or pleural
fluid
• Causes include Streptococcus pneunwniae, Haemophi/us infiuenwe,
gram-negative rods, Staphylococcus aureus, legionella
• In ventilator-associated pneumonia, an invasive diagnostic strategy
including bronchoscopy may reduce mortality
• Differential Diagnosis
• Lung abscess
• Pulmonary embolism
• Myocardial infarction
• Atypical or viral pneumonia
• Bronchiolitis obliterans with organizing pneumonia (BOOP)
• Treatment
• Empiric antibiotics for common organisms after obtaining cultures
• Hospitalize selected patients (severe hypoxemia, more than one
lobe involved, poor host resistance factors, presence of coexisting
illness, leukopenia or marked leukocytosis, hypotension)
• Pneumococcal vaccine can prevent or lessen the severity of pneumococcal
infections in up to 90% of patients
• Pearl
When gram-positive diplococci thrive in neutrophi/s, think staphylococci,
not pneumococci.
Reference
Bartlett JG et al: Community-acquired pneumonia in adults: guidelines for management.
The Infectious Diseases Society of America. Clin Infect Dis 1998;
26:811. [PMID: 9564457]
Chapter 2 Pulmonary Diseases 51
+
Atypical Pneumonia
• Essentials of Diagnosis
• Cough with scant sputum, fever, malaise, headache; gastrointestinal
symptoms variable
• Physical examination of lungs may be unimpressive
• Mild leukocytosis; cold agglutinins sometimes positive but not
diagnostic
Patchy, non lobar infiltrate by chest x-ray often surprisingly extensive
• Pathogens include mycoplasma, chlamydia, viral agents
• Typical and atypical pneumonia not always distinguishable by
clinical or radiographic features
• Differential Diagnosis
• Bacterial pneumonia
• Pulmonary embolism
• Congestive heart failure
• Bronchiolitis obliterans with organizing pneumonia (BOOP)
• Idiopathic pulmonary fibrosis
• Hypersensitivity pneumonitis
• Treatment
• Empiric antibiotic treatment with doxycycline, erythromycin,
or newer macrolide (eg, azithromycin) or fluoroquinolone (eg,
levofloxacin)
• Hospitalize as for bacterial pneumonia
• Pearl
In psittacosis, the history ofparrot exposure may be difficult to obtain
because ofillegal importation ofthe bird.
Reference
Bartlett JG et aI: Community-acquired pneumonia in adults: guidelines for management.
The Infectious Diseases Society of America. Clin Infect Dis
1998;26:811. [PMlD: 9564457]
+
52 Essentials of Diagnosis & Treatment
Anaerobic Pneumonia & Lung Abscess
• Essentials of Diagnosis
• Cough producing foul-smelling sputum; hemoptysis; fever, weight
loss, malaise
• Patients with periodontal disease, history of impaired deglutition
(eg, neurologic or esophageal disorder or altered consciousness)
are predisposed
Bronchial breath sounds with dullness and egophony over involved
lung
• Leukocytosis; hypoxemia
• Chest x-ray density, often with central lucency or air-fluid level
• Sputum cultures reveal only mouth flora
• Differential Diagnosis
• Tuberculosis
• Bronchogenic carcinoma
• Pulmonary mycoses
• Bronchiectasis
• Cavitary bacterial pneumonia
• Pulmonary vasculitis (eg, Wegener's granulomatosis)
• Treatment
• Clindamycin or high-dose penicillin (treatment for 6 or more
weeks)
• Surgery in selected cases (massive abscess; massive or persistent
hemoptysis)
• Supplemental oxygen as needed
• Bronchoscopic exclusion of carcinoma or foreign body aspiration
in patients with atypical features, especially edentulous patients
• Pearl
A lung abscess in an edentulous patient is lung cancer until proved
otherwise.
Reference
Bartlett, JG et al: Community-acquired pneumonia in adults: guidelines for management.
The Infectious Diseases Society of America. Clin Infect Dis 1998;
26:81 I. [pMlD: 9564457]
Chapter 2 Pulmonary Diseases 53
+
Pulmonary Tuberculosis
• Essentials of Diagnosis
• Lassitude, weight loss, fever, cough, night sweats, hemoptysis;
may be asymptomatic, however
• Cachexia in many; posttussive apical rales occasionally present
• Apical or subapical infiltrates with cavities classic in reactivation
tuberculosis; pleural effusion in primary tuberculosis, likewise
mid-lung infiltration, but any radiographic abnormality is possible
Positive skin test to intradermal purified protein derivative (PPD)
in most
• Mycobacterium tuberculosis by culture of sputum, pieural fluid,
gastric washing, or pleural biopsy; pleural fluid culture usually
sterile, however
• Increasing antibiotic-resistant strains
• Granuloma on pleural biopsy in patients with effusions; mesothelial
cells usually absent from fluid
• Differential Diagnosis
• Bronchogenic carcinoma
• Bacterial pneumonia or lung abscess
• Fungal infection
Sarcoidosis
Pneumoconiosis
Pleural effusion of asbestosis
Other mycobacterial infections
• Treatment
• Combination antituberculous therapy for 6-9 months; all regimens
include isoniazid, but rifampin, ethambutol, pyrazinamide,
streptomycin all have activity
• All cases of suspected M tuberculosis infection reported to local
health departments
Hospitalization should be considered for those incapable of selfcare
or likely to expose susceptible individuals
• Pearl
With respect to pulmonary tuberculosis and HlV infection-if it looks
like tuberculosis it isn't, and if it doesn't it is.
Reference
Diagnostic Standards and Classification of Tuberculosis in Adults and Children.
This official statement of the American Thoracic Society and the Centers for
Disease Control and Prevention was adopted by the ATS Board of Directors,
July 1999. This statement was endorsed by the Council of the Infectious Disease
Society of America, September 1999. Am J Respir Crit Care Med
2000; 161 (4 Pan 1): 1376. [PMID: 10764337]
+
54 Essentials of Diagnosis & Treatment
Idiopathic Pulmonary Fibrosis
(Usual Interstitial Pneumonia)
• Essentials of Diagnosis
• Insidious onset of dyspnea and dry cough in patients usually in
their sixth or seventh decades
• Inspiratory crackles by auscultation; clubbing
• Hypoxemia, especially exertional; antinuclear antibody and rheumatoid
factor often positive but nonspecific
• Diffuse interstitial infiltration by chest x-ray, which may progress
to honeycombing pattern
Restrictive pattern with decreased total lung capacity and diffusing
capacity (DLco)
• High-resolution thoracic CT scan helpful
• Thoracoscopic and open lung biopsy are best methods for definitive
diagnosis; cellular pattern on bronchoalveolar lavage also
helpful
• Differential Diagnosis
• Bronchiolitis obliterans organizing pneumonia (BOOP)
• Interstitial lung disease due to infection
• Drug-induced fibrosis (eg, bleomycin, nitrofurantoin)
• Sarcoidosis
• Pneumoconiosis
• Asbestosis
• Hypersensitivity pneumonitis
• Treatment
• Supportive therapy, including supplemental oxygen
• High-dose oral corticosteroids ineffective
• Adjunctive cytotoxic therapy in selected patients may improve
outcome
• Early referral to lung transplantation center is critical for good
candidates; gamma interferon is a promising new therapy
• Pearl
Progression from desquamative interstitial pneumonia to usual interstitial
pneumonia does not occur; the former is a nonspecific alveolar
response to smoking.
Reference
American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment.
International consensus statement. AmeIican Thoracic Society (ATS),
and the European Respiratory Society (ERS). Am J Respir Crit Care Med
2000;161(2 Part 1):646. [PMID: 10673212]
+
Chapter 2 Pulmonary Diseases 55
Sarcoidosis
• Essentials of Diagnosis
• A disease of unknown cause with an increased incidence in North
American blacks and Northern European whites
• Malaise, fever, dyspnea of insidious onset; symptoms referable
to eyes, skin, nervous system, liver, or heart also common; often
presents asymptomatically
Iritis, erythema nodosum, parotid enlargement, lymphadenopathy,
hepatosplenomegaly
Hypercalcemia (5%) less common than hypercalciuria (20%)
Pulmonary function testing may show evidence of obstruction,
but restriction with decreased DLco is more common
• Symmetric hilar and right paratracheal adenopathy, interstitial
infiltrates, or both seen on chest x-ray
• Tissue reveals noncaseating granuloma; transbronchial biopsy
gives high yield, even without parenchymal disease on chest film
• Increased angiotensin-converting enzyme levels are neither sensitive
nor specific; cutaneous anergy in 70%
• Differential Diagnosis
• Tuberculosis
• Lymphoma, including lymphocytic interstitial pneumonitis
Histoplasmosis or coccidioidomycosis
• Idiopathic pulmonary fibrosis
• Pneumoconiosis
• Berylliosis
• Treatment
• Oral systemic corticosteroid therapy indicated for symptomatic
pulmonary disease, cardiac involvement, iritis unresponsive to
local therapy, hypercalcemia, central nervous system involvement,
arthritis, skin disease
Asymptomatic patients with normal pulmonary function may
not require corticosteroids-they should receive close clinical
follow-up
• Pearl
The only disease in medicine in which steroids reverse anergy.
Reference
Statement on sarcoidosis. Am J Respir Ceit Care Med 1999;160:736. [PMID:
10430755]
+
56 Essentials of Diagnosis & Treatment
Pulmonary Thromboembolism
• Essentials of Diagnosis
• Seen in immobilized patients, congestive failure, malignancies,
and after pelvic trauma or surgery
• Abrupt onset of dyspnea and anxiety, with or without pleuritic
chest pain, cough with hemoptysis; syncope rare, but suggestive
of extensive disease
• Tachycardia, tachypnea, most common; loud P2 with right-sided
S3 characteristic but unusual; findings of peripheral venous thrombosis
often absent
• Acute respiratory alkalosis and hypoxemia
• Characteristic perfusion defect on ventilation-perfusion scan,
confirmed by pulmonary angiography in selected patients
• Lower extremity ultrasound will demonstrate deep venous thrombosis
in about half of cases
• Spiral CT scan is newly emerging diagnostic technique with
unclear utility
• Differential Diagnosis
• Pneumonia
• Myocardial infarction
• Atelectasis
• Any cause of acute respiratory distress (eg, pneumothorax, aspiration,
pulmonary edema, or asthma) or pleural effusion
• Early sepsis
• Dressler's syndrome
• Treatment
• Anticoagulation: acutely with heparin for several days, instituting
warfarin concurrently and continuing for a minimum of 3 months
• Thrombolytic therapy initially in selected patients with hemodynamic
compromise, but no effect on mortality
• Intravenous filter placement in inferior vena cava for selected
patients not candidates for or unresponsive to anticoagulation
• Pearl
Ten percent ofpulmonary emboli originate from upper extremity veins.
Reference
Rathbun SW et al: Sensitivity and specificity of helical computed tomography
in the diagnosis of pulmonary embolism: a systematic review. Ann Intern
Med 2000;132:227. [PMTD: 10651604]
Chapter 2 Pulmonary Diseases 57
+
Primary Pulmonary Hypertension
• Essentials of Diagnosis
• A rare disorder seen primarily in young and middle-aged women
• Defined as pulmonary hypertension and elevated peripheral vascular
resistance in the absence of lung or heart disease
• Progressive dyspnea, malaise, chest pain, exertional syncope
• Tachycardia, right ventricular lift, increased P
"
systolic ejection
click, right-sided S3; may have evidence of right-sided heart failure
(peripheral edema, hepatomegaly, ascites)
• Right ventricular strain or hypertrophy by electrocardiography
• Large central pulmonary arteries by chest x-ray, with oligemia
distally
• Characteristic plexogenic arteriopathy on pathologic examination
• Differential Diagnosis
• Mitral stenosis
• Sleep apnea
• Chronic pulmonary embolism
• Autoimmune disease
• Ischemic heart disease
• Congenital heart disease
• Cirrhosis of the liver with portal hypertension
• Pulmonary veno-occlusive disease
• Treatment
• Continuous intravenous prostacyclin infusion improves survival
• Empiric anticoagulation may confer survival benefit
• Other vasodilator agents of unpredictable and uncertain efficacy
• Bilateral lung or heart-lung transplantation important options; all
eligible patients should be referred to a transplant center for evaluation
• Pearl
All murmurs ofmitral stenosis may be missing in that condition, leading
to an inaccurate diagnosis ofprimary pulmonary hypertension.
Reference
Gaine SP et al: Primary pulmonary hypertension. Lancet 1998;352:719. [PMlD:
9729004]
+
58 Essentials of Diagnosis & Treatment
Silicosis
• Essentials of Diagnosis
• A typical pneumoconiosis: a chronic fibrotic lung disease caused
by the inhalation of various dusts
• History of extensive prolonged exposure to dust containing silicon
dioxide (eg, foundry work, sandblasting, hard rock mining)
• Progressive dyspnea, often over months to years
Dry inspiratory crackles by auscultation
• Characteristic changes on chest radiograph with bilateral fibrosis
and nodules (upper greater than lower lobes), hilar lymphadenopathy
with "eggshell" calcification
• Pulmonary function studies yield mixed obstructive and restrictive
pattern
• Differential Diagnosis
• Other inhalation pneumoconioses (eg, asbestosis)
• Tuberculosis (often complicates silicosis)
• Sarcoidosis
• Histoplasmosis
• Coccidioidomycosis
• Idiopathic pulmonary fibrosis
• Treatment
• Supportive care; chronic oxygen if sustained hypoxemia present
• Chemoprophylaxis with isoniazid necessary for all silicotic patients
with positive tuberculin reactivity (given the markedly increased
incidence of tuberculosis in silicosis)
• Pearl
One of the associations with tuberculosis which is paradoxical; many
clinically similar processes do not share this association.
Reference
Mossman BT et al: Mechanisms in the pathogenesis of asbestosis and silicosis.
Am J Respir Crit Care Med 1998;157(5 Part 1):1666. [PMID: 9603153]
+
Chapter 2 Pulmonary Diseases 59
Asbestosis
• Essentials of Diagnosis
• History of exposure to dust containing asbestos particles (eg,
from work in mining, insulation, construction, shipbuilding)
• Progressive dyspnea, rarely pleuritic chest pain
• Dry inspiratory crackles common; clubbing and cyanosis occasionally
seen
Interstitial fibrosis, later coalescing into nodules, is characteristic
(lower field greater than upper field); pleural thickening, plaques,
and diaphragmatic calcification common but unrelated to parenchymal
disease; in some, exudative pleural effusion develops
before parenchymal disease
• High-resolution CT scan often confirmatory
• Pulmonary function testing shows a restrictive defect with a diminished
DLco often the earliest abnormality
• Differential Diagnosis
• Other inhalation pneumoconioses (eg, silicosis)
• Fungal disease
• Sarcoidosis
• Idiopathic pulmonary fibrosis
• Mesothelioma
• Treatment
• Supportive care; chronic oxygen supplementation for sustained
hypoxemia
• Legal counseling regarding compensation for occupational
exposure
• Pearl
Remember that the highest exposures on ships or boats come from
sweeping the floor on submarines, not working on the structure of the
vessel.
Reference
Wagner GR: Asbestosis and silicosis. Lancet 1997;349: 1311. [PMlD: 9142077]
+
60 Essentials of Diagnosis & Treatment
Pulmonary Alveolar Proteinosis
• Essentials of Diagnosis
• May be idiopathic or secondary (ie, post lung infection, immunocompromised
host)
• Progressive dyspnea and low-grade fever
• Physical examination often normal
• Hypoxemia; bilateral alveolar infiltrates suggestive of pulmonary
edema on chest radiography
• Characteristic intra-alveolar phospholipid accumulation without
fibrosis at open lung biopsy
• Superinfection with nocardia or fungi may occur
• Differential Diagnosis
• Congestive heart failure
• Acute pneumonia
• Bronchiolitis obliterans with organizing pneumonia (BOOP)
• Treatment
• Periodic whole lung lavage reduces exertional dyspnea
• Natural history variable with occasional spontaneous remissions
seen
• Pearl
Ifthe lab tells you they seefaintly acid-fast organisms on a screen ofthe
sputum in a patient with new-onset "pulmonary edema, " here is your
diagnosis.
Reference
Wang 8M et al: Diagnosing pulmonary alveolar proteinosis. A review and an
update. Chest 1997;111 :460. [PMID: 9041997]
Chapter 2 Pulmonary Diseases 61
+
Chronic Eosinophilic Pneumonia
• Essentials of Diagnosis
• Fever, dry cough, wheezing, dyspnea, and weight loss-all variable
from transient to severe and progressive
• Wheezing, dry crackles occasionally appreciated by auscultation
• Peripheral blood eosinophilia present in most cases
• Peripheral pulmonary infiltrates on radiographs in many cases (ie,
"the radiologic negative" of pulmonary edema) shown to be eosinophilic
by bronchoalveolar lavage or open lung biopsy
• Differential Diagnosis
• Acute infectious pneumonia
• Asthma
• Idiopathic pulmonary fibrosis
• Bronchiolitis obliterans with organizing pneumonia (BOOP)
• Allergic bronchopulmonary aspergillosis
• Churg-Strauss syndrome
• Other eosinophilic pulmonary syndromes (eg, drug or parasiterelated)
• Treatment
• Corticosteroid therapy often results in dramatic improvement in
idiopathic cases; recurrence is common
• Most patients require corticosteroid therapy for a year or more
(sometimes indefinitely)
• Pearl
Always pause and consider strongyloidiasis before giving steroids to a
patient with pulmonary disease and eosinophilia.
Reference
Allen IN et aJ: Eosinophilic lung diseases. Am J Respir Crit Care Med
1994; 150(5 Pan 1):1423. [PMlD: 7952571]
+
62 Essentials of Diagnosis & Treatment
Hypersensitivity Pneumonitis
• Essentials of Diagnosis
• Work and environmental history suggesting link between activities
and symptoms
Acute form: 4-12 hours after exposure, onset of cough, dyspnea,
fever, chills, myalgias; tachypnea, tachycardia, inspiratory crackles;
leukocytosis with lymphopenia and neutrophilia; eosinophilia
unusual
• Subacute or chronic fonn: exertional dyspnea, cough, fatigue,
anorexia, weight loss; basilar crackles
• Caused by exposure to microbial agents (eg, thermophilic actinomyces
in farmer's lung, aspergillus), animal proteins (eg, bird
fancier's lung) with resultant IgG complement deposition, and
chemical sensitizers (eg, isocyanates, trimetallic anhydride)
• IgG precipitating antibodies are not sensitive or specific-markers
of antigen exposure, not disease
• Pulmonary function tests reveal restrictive pattern and decreased
OLeo
• High-resolution thoracic CT scan reveals fine reticulonodular
pattern or diffuse ground-glass appearance
• Bronchoalveolar lavage reveals marked lymphocytosis
• Transbronchial or thoracoscopic lung biopsy can confinn diagnosis
in unclear cases
• Differential Diagnosis
• Sarcoidosis
• Asthma
• Atypical pneumonia
• Collagen-vascular disease, eg, systemic lupus erythematosus
• Idiopathic pulmonary fibrosis
• Lymphoma
• Treatment
• Identification and removal of exposure is essential
• Consider systemic corticosteroids in subacute or chronic fonns
• Pearl
Bagassosis and sequoiosis are two examples: a history ofexposure to
sugar cane orfallen lumber, respectively, makes the diagnosis.
Reference
Kaltreider HE. Hypersensitivity pneumonitis. West J Med 1993; 159:570. [PMID:
8279154]
Chapter 2 Pulmonary Diseases 63
+
Sleep-Related Breathing Disorders (Sleep Apnea)
• Essentials of Diagnosis
• Excessive daytime somnolence or fatigue, morning headache,
weight gain, erectile dysfunction; bed partner may report restless
sleep and loud snoring
• Obesity, systemic hypertension common; signs of pulmonary
hypertension or cor pulmonale may develop over time in a few
• Erythrocytosis common
• Sleep study-either formal polysomnography or a screening
study-reveals periods of apnea
• Most cases are of mixed central or obstructive origin; pure central
sleep apnea is rare
• Differential Diagnosis
• Alcohol or sedative abuse
• Narcolepsy
• Depression
• Seizure disorder
• Chronic obstructive pulmonary disease
• Hypothyroidism
• Treatment
• Weight loss and avoidance of sedatives or hypnotic medications
mandatory
• Nocturnal nasal continuous positive airway pressure (CPAP) and
supplemental oxygen frequently abolish obstructive apnea
• Protriptyline effective in minority of patients
• Surgical approaches (uvulopalatopharyngoplasty, nasal septoplasty.
tracheostomy) reserved for selected cases
• Pearl
When a plethoric clinic patient nods off during the history, it's sleep
apnea until proved othenvise; ifthe historian docs, it's a post-call resident.
Reference
Piccirillo IF et al: Obstructive sleep apnea. lAMA 2000;284: 1492. [PMlD: CUI:
11000621]
3
GaS'lrointestinal Diseases
Gastroesophageal Reflux Disease
• Essentials of Diagnosis
• Substernal burning (pyrosis) or pressure, aggravated by recumbency
and relieved with sitting; waterbrash, dysphagia; nocturnal
regurgitation, cough, or wheezing common
• Esophageal reAux or hiatal hernia may be found by Auoroscopy
at barium study; iron deficiency anemia secondary to occult blood
loss may be encountered
• Manometry reveals incompetent lower esophageal sphincter;
endoscopy with biopsy may be necessary for diagnosis
• Esophageal pH monitoring helpful in excluding disease when
symptoms are present during monitoring
• Conditions associated with diminished lower esophageal sphincter
tone include obesity, pregnancy, hiatal hernia, nasogastric tube,
recurrent emesis, and Raynaud's phenomenon
• Differential Diagnosis
• Peptic ulcer disease
• Cholecystitis
• Angina pectoris
• Achalasia
• Esophageal spasm • Treatment
• Weight loss if indicated, avoidance of late-night meals or snacks,
elevation of head of bed
• Avoid substances reducing lower esophageal sphincter tone
(chocolate, caffeine, tobacco, alcohol, fried or fatty foods)
• Antacids, high-dose H2 blockers, or proton pump inhibitors (eg,
omeprazole)
• Gastrointestinal motility stimulants (eg, bethanechol, metoclopramide)
in selected patients
• Surgical fundoplication via abdominal (Hill, Nissen) or thoracic
(Belsey) approach for rare cases refractory to medical management
• Pearl
Eradication of Helicobacter pylori may actually worsen GERD by
increasing gastric acid secretioll.
Reference
Katzka DA: Digestive system disorders: gastroesophageal reflux disease. West
J Med 2000; 173:48.
64
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 3 Gastrointestinal Diseases 65
Diffuse Esophageal Spasm
• Essentials of Diagnosis
• Dysphagia, substernal pain, hypersaJivation, reflux of recently
ingested food
• May be precipitated by ingestion of hot or cold foods
• Endoscopic, radiographic, and manometric demonstration of nonpropulsive
hyperperistalsis; lower esophageal sphincter relaxes
normally
• "Nutcracker esophagus" variant with prolonged, high pressure
(> 175 mm Hg) propulsive contractions
• Differential Diagnosis
• Angina pectoris
• Esophageal or mediastinal tumors
• Aperistalsis
• Achalasia
• Psychoneurosis
• Treatment
• Nitrates often effective
• Esophageal myotomy for refractory patients with severe disease
• Pearl
Like all esophageal motor disorders, consider myocardial ischemia as
responsible until proved otherwise.
Reference
Patti MG et al: Evaluation and treatment of primary esophageal motility disorders.
WestJ Med 1997; J66:263.
+
66 Essentials of Diagnosis & Treatment
Achalasia
• Essentials of Diagnosis
• Progressive dysphagia, odynophagia, and regurgitation of undigested
food
• Barium swallow demonstrates a dilated upper esophagus with a
narrowed cardioesophageal junction ("bird's beak" esophagus);
chest x-ray may reveal a retrocardiac air-fluid level
• Lack of primary peristalsis by manometry or cineradiography and
incomplete lower esophageal sphincter relaxation with swallowing
• Differential Diagnosis
• Diffuse esophageal spasm
• Aperistalsis
• Benign lower esophageal stricture
• Esophageal or mediastinal tumors (esophageal carcinoma may
complicate achalasia, however)
• Scleroderma of esophagus
• Treatment
• Nifedipine, 10-20 mg sublingually 30 minutes before meals
Botulinum toxin injection endoscopically in patients who are not
good surgical candidates
• Pneumatic esophageal dilation
• Surgical extramucosal myotomy (esophagocardiomyotomy) in
refractory cases
• Consider yearly esophagoscopy to evaluate for carcinoma
• Pearl
In patients with retrocardiac air-fluid levels on chest x-ray, consider
this diagnosis-it's not always a lung abscess.
Reference
Bassotti G et aI: Review anicle: pharmacological options in achalasia. Aliment
Pharmacal Therap 1999; 13:1391.
Chapter 3 Gastrointestinal Diseases 67
Esophageal Web
• Essentials of Diagnosis
• Dysphagia
• Plummer-Vinson syndrome if associated with iron deficiency
anemia, glossitis, and spooning of nails; may be higher incidence
of hypopharyngeal carcinoma
• Barium swallow (lateral view often required), esophagoscopy
diagnostic (but often misses cervical esophageal webs)
• Differential Diagnosis
• Achalasia
• Esophageal diverticulum
• Aperistalsis
• Esophageal or mediastinal tumor
• Esophageal stricture
• Treatment
• Treat the iron deficiency after finding its cause-the web may
resolve spontaneously
• Esophagoscopy with disruption of webs adequate in most cases
Bougienage required on occasion
• Pearl
Webs do not cause iron deficiency; the iron deficiency comesjirst, and
the web is a connective tissue effect oflow iron.
Reference
Chung Set al: Gastrointestinal: upper oesophageal web. J Gastroellterol Hepatology
1999; 14:61 l.
+
68 Essentials of Diagnosis & Treatment
Benign Stricture of Esophagus
• Essentials of Diagnosis
• Dysphagia for solids more than liquids; odynophagia
• Smooth narrowing of lumen radiographically; esophagoscopy
and biopsy or cytology mandatory to exclude malignancy
• Onset months to years following esophageal insult, including
gastroesophageal reflux, indwelling nasogastric tube, corrosive
ingestion, infectious esophagitis, or endoscopic injury
• Differential Diagnosis
• Achalasia
• Esophageal or mediastinal tumor
• Esophageal web
• Schatzki's ring
• Left atrial enlargement
• Pericardial effusion
• Treatment
• Monthly bougienage dilation is definitive therapy for most patients
• Surgical therapy required rarely
• Pearl
When reflux is the cause, be waf)' ofadenocarcinoma developing within
columnar metaplasia induced by the acid (see next page).
Reference
Johanson JF: Epidemiology of esophageal and supraesophageal reflux injuries.
Am J Med 2000; I 08(Suppl 4a):99S.
+
Chapter 3 Gastrointestinal Diseases 69
Barrett's Esophagus
• Essentials of Diagnosis
• Dysphagia, heartburn, regurgitation in supine position
• Upper endoscopy with biopsy reveals columnar epithelium replacing
squamous epithelium
• May be complicated by esophageal stricture or, in area of columnar
epithelium, ulceration
• Esophageal adenocarcinoma may develop in up to 10% of patients
• Differential Diagnosis
• Achalasia
• Esophageal or mediastinal tumor
• Esophageal web
• Benign stricture
• Left atrial enlargement or pericardial effusion
• Treatment
• Acid suppression (pH> 4) with proton pump inhibitors
• Surgical fundoplication in selected patients
• Endoscopic laser or photodynamic therapy in selected patients
with dysplasia who are not surgical candidates
• Surveillance esophagoscopy with biopsy at 1- or 2-year intervals
• Pearl
When brisk upper gastrointestinal bleeding occurs in a patient with
Barrett's esophagus, suspect cardioesophagealfistula.
Reference
Bremner CG et al: Barrett's esophagus. Surg Clin North Am 1997;77:1115.
+
70 Essentials of Diagnosis & Treatment
Mallory-Weiss Syndrome
(Mucosal Laceration of the Gastroesophageal Junction)
• Essentials of Diagnosis
• Because many patients are hypovolemic, portal pressure is low
and bleeding not impressive
• Hematemesis of bright red blood, often following prolonged or
forceful vomiting or retching; majority lack this history
• More impressive in alcoholics with brisk bleeding because of
associated esophageal varices
• Endoscopic demonstration of vertical mucosal tear at cardioesophageal
junction or proximal stomach
• Hiatal hernia often associated
• Differential Diagnosis
• Peptic ulcer
• Esophageal varices
• Gastritis
• Reflux, infectious, or pill esophagitis
• Treatment
• Usually none required; spontaneous resolution of bleeding unless
concomitant varices present
• Endoscopic hemostatic intervention with epinephrine injection or
thermal coaptation for active bleeding; rarely, balloon tamponade,
embolization, or surgery is required for uncontrolled bleeding
• Pearl
Hyperemesis ofpregnancy is the most common cause, but bleeding is
seldom reported by the patient since it is trivial due to absence offactors
noted in alcoholics.
Reference
Bharucha AE et al: Clinical and endoscopic risk factors in the Mallory-Weiss
syndrome. Am J Gastroenterol 1997;92:805.
+
Chapter 3 Gastrointestinal Diseases 71
Emetogenic Esophageal Perforation
(Boerhaave's Syndrome)
• Essentials of Diagnosis
• History of alcoholic binge drinking, excessive and rapid food intake,
or both
• Violent vomiting or retching followed by sudden pain in chest or
abdomen, odynophagia, dyspnea
• Fever, shock, profound systemic toxicity, subcutaneous emphysema,
mediastinal crunching sounds, rigid abdomen, tachypnea
• Leukocytosis, salivary hyperamylasemia
• Chest x-ray shows mediastinal widening, mediastinal emphysema,
pleural effusion (often delayed)
• Demonstration of rupture of lower esophagus by esophagogram
with water-soluble opaque media or cr scan; no role for endoscopy
• Differential Diagnosis
• Myocardial infarction, pericarditis
• Pulmonary embolism, pulmonary abscess
• Aortic dissection
• Ruptured viscus
• Acute pancreatitis
• Shock due to other causes
• Caustic ingestion, pill esophagitis
• Instrumental esophageal perforation
• Treatment
• Aggressive supportive measures with broad-spectrum antibiotics
covering mouth organisms, nasogastric tube suctioning, and total
parenteral nutrition
• Surgical consultation with repair
• Pearl
One ofthe few causes in medicine ofhydrophobia.
Reference
Achem, SR: Boerhaave's syndrome. Dig Dis 1999;17:256.
-
+
72 Essentials of Diagnosis & Treatment
Foreign Bodies in the Esophagus
• Essentials of Diagnosis
• Most common in children, edentulous older patients, and the
severely mentaJly impaired
• Occurs at physiologic areas of narrowing (upper esophageal sphincter,
the level of the aortic arch, or the diaphragmatic hiatus)
• Other predisposing factors favoring impaction include Zenker's
diverticulum, webs, achalasia, peptic strictures, or malignancy
• Recent ingestion of food or foreign material (coins most commonly
in children), but the history may be missing
• Vague discomfort in chest or neck, dysphagia, inability to handle
secretions, odynophagia, hypersalivation, and stridor or dyspnea
in children
• Radiographic or endoscopic evidence of esophageal obstruction
by foreign body
• Differential Diagnosis
• Esophageal stricture
• Esophageal or mediastinal tumor
• Angina pectoris
• Treatment
• Endoscopic removal with airway protection as needed and the use
of an overtube if sharp objects are present
• Emergent endoscopy should be used for sharp objects, disk batteries
(secondary to risk of perforation due to their caustic
nature), or evidence of the inability to handle secretions
• Endoscopy is successful in over 90% of cases
• Observation and delayed endoscopy may be considered if the
patient is without symptoms and radiologic studies are negative
• Pearl
Treatment is ordinarily straightforward; diagnosis may not be.
Reference
Stack LB et al: Foreign bodies in the gastrointestinal tract. Emerg Med Clin
North Am 1996;493.
+
Chapter 3 Gastrointestinal Diseases 73
Gastritis
• Essentials of Diagnosis
• May be acute (erosive) or indolent (atrophic)
• Symptoms often vague and include nausea, vomiting, anorexia,
nondescript upper abdominal distress; significant hemorrhage
may occur with or without symptoms
• Mild epigastric tenderness to palpation; in some, physical signs
absent
• Iron deficiency anemia not unusual
• Endoscopy with gastric biopsy for definitive diagnosis
• Multiple associations include stress (burns, sepsis, critical illness),
drugs (NSAIDs, salicylates), atrophic states (aging, pernicious
anemia), previous surgery (gastrectomy, Billroth II), Helicobacter
pylori infection, acute or chronic alcoholism
• Differential Diagnosis
• Peptic ulcer
• Hiatal hernia
• Mal ignancy of stomach or pancreas
• Cholecystitis
• Ischemic cardiac disease
• Treatment
• Avoidance of alcohol, caffeine, salicylates, tobacco, and NSAIDs
• Investigate for presence of Helicobaeter pylori; eradicate if present
• Proton pump inhibitors in patients receiving oral feedings, H2
inhibitors, or sucralfate
• Prevention in high-risk patients (eg, intensive care setting) using
these same agents
• Pearl
Ninety-five percent of gastroenterologists and a high proportion of
other health care workers carry H pylori.
Reference
Tytgat GN: Ulcers and gastritis. Endoscopy 2000;32:108.
+
74 Essentials of Diagnosis & Treatment
Duodenal Ulcer
• Essentials of Diagnosis
• Epigastric pain 45--60 minutes following meals or nocturnal pain,
both relieved by food or antacids, sometimes by vomiting; symptoms
chronic and periodic; radiation to back common
• Iron deficiency anemia, positive fecal occult blood; amylase
elevated with posterior penetration
Ulcer crater or deformity of duodenal bulb demonstrated radiographically
or endoscopically
• Caused by Helicobacter pylori in 70% of cases, NSATDs in
20-30%, Zollinger-Ellison syndrome in less than 1%; H pylori
infection may be diagnosed serologically
• Complications include hemorrhage, intractable pain, perforation,
and obstruction
• Differential Diagnosis
• Reflux esophagitis
• Gastritis
• Pancreatitis
• Cholecystitis
• Other peptic disease, eg, Zollinger-Ellison syndrome or gastric
ulcer
• Treatment
• Eradicate H pylori when present
• Avoid tobacco, alcohol, xanthines, and ulcerogenic drugs, especially
NSAIDs
• H2 blockers, proton pump inhibitors, and sucralfate
Surgery-now far less common-may be needed for ulcers refractory
to medical management (rare) or for the management of
complications (eg, perforation, uncontrolled bleeding); supraselective
vagotomy preferred unless patient unstable or is obstructed
• Pearl
Once an ulcer, always an ulcer. Patients with first episodes have a
higher incidence ofrecurrence throughout life.
Reference
Wilcox eM: Relationship between nonsteroidal anti-inflammatory drug use,
Helicobacter pylori, and gastroduodenal mucosal injury. Gastroenterology
1997; 113(6 Suppl):S85.
+
Chapter 3 Gastrointestinal Diseases 75
Zollinger-Ellison Syndrome (Gastrinoma)
• Essentials of Diagnosis
• Severe, recurrent, intractable peptic ulcer disease, often associated
with concomitant esophagitis; ulcers may be in atypicallocations,
like jejunum, but most in usual sites
• Eighty percent of cases are sporadic; the rest are associated with
multiple endocrine neoplasia type 1 (MEN 1)
Serum gastrin> 150 pg/mL (often much higher) in the setting of
a low gastric pH; elevated serum chromogranin A
• Diarrhea common, caused by inactivation of pancreatic enzymes;
relieved by nasogastric tube suctioning immediately
Gastrinomas may arise in pancreas, duodenum, or lymph nodes;
over 50% are malignant but not usually aggressive
• Localization techniques include somatostatin receptor scintigraphy,
thin-cut CT, MRI, endoscopic ultrasound, or intraoperative
localization
• Differential Diagnosis
• Peptic ulcer disease of other cause
• Esophagitis
Gastritis
• Pancreatitis
• Cholecystitis
Diarrhea or malabsorption from other causes
• Treatment
• High-dose proton pump inhibitor (with goal of < 10 meq/h of
gastric acid secretion)
Exploratory laparotomy for patients without preoperative evidence
of unresectable metastatic disease
• Chemotherapy ineffective; interferon, octreotide, and hepatic
artery embolization, for metastatic disease
Resection for localized disease
• Family counseling
• MEN I-associated gastrinoma appears to have a lower incidence
of hepatic metastases and a better long-term prognosis
• Pearl
In Zollinger-Ellison syndrome, isolated gastric ulcer is never encountered.
Reference
Qureshi Wet al: Zollinger-Ellison syndrome. Improved treatment options for
this complex disorder. Postgrad Med 1998;104:155.
+
76 Essentials of Diagnosis & Treatment
Gastric Ulcer
• Essentials of Diagnosis
• Epigastric pain unpredictably relieved by food or antacids; weight
loss, anorexia, vomiting
• Iron deficiency anemia, fecal occult blood positive
• Ulcer demonstrated by barium study or endoscopy
• Caused by Helicobacter pylori (in 70% of cases), NSAlDs, gastric
malignancy, Zollinger-Ellison syndrome
• Endoscopic biopsy or documentation of complete healing necessary
to exclude malignancy
• Complications include hemorrhage, perforation, and obstruction
• Differential Diagnosis
• Other peptic ulcer disease
• Gastric carcinoma
• Cholecystitis
• Esophagitis
• Gastritis
• Irritable or functional bowel disease
• Treatment
• Eradicate H pylori when present
• Avoid tobacco, alcohol, xanthines, and ulcerogenic drugs, especially
NSAIDs
• Proton pump inhibitors, sucralfate, H2 receptor antagonists
• Surgery may be needed for ulcers refractory to medical management
(rare) or for the management of complications (eg, perforation,
uncontrolled bleeding)
• Pearl
Gastric ulcers lose weight; duodenal ulcers gain it.
Reference
Barkin J: The relation between Helicobacter pylori and nonsteroidal anti-inflammatory
drugs. Am J Med 1998;105(5A):22S.
+
Chapter 3 Gastrointestinal Diseases 77
Crohn's Disease
• Essentials of Diagnosis
• Insidious onset, with intermittent bouts of diarrhea, low-grade
fever, right lower quadrant pain; peripheral arthritis, spondylitis;
rash less common but may be presenting symptom
• Complications include fistula formation, perianal disease with
abscess, right lower quadrant mass and tenderness
Anemia, leukocytosis, positive fecal occult blood
• Radiographic findings of thickened, stenotic bowel with ulceration,
strictu ring, or fistulas; characteristic skip areas
• Histologic demonstration of submucosal inflammation with fibrosis
and granulomatous lesions
• Differential Diagnosis
• Ulcerative colitis
• Appendicitis
• Diverticulitis
• Intestinal tuberculosis
• Mesenteric adenitis
• Lymphoma, other tumors of small intestine
• Miscellaneous arthropathies and skin diseases
• Treatment
• Low-residue, lactose-free diet, antidiarrheals, antispasmodics,
vitamin BI2 and calcium supplementation as needed
• Sulfasalazine or mesalamine for colonic disease
• Corticosteroids or mercaptopurine for acute flares or extraintestinal
complications
• Infliximab for refractory or fistulous disease
• Surgery for refractory obstruction, fistula, or abscess
• Pearl
Ileocecal disease is present in 40 50%, isolated small bowel disease in
30-40%, and isolated colonic disease in 20%.
Reference
Rampton DS: Management ofCrohn's disease. EM] 1999;319:1480.
+
78 Essentials of Diagnosis & Treatment
Celiac &Tropical Sprue
• Essentials of Diagnosis
• Caused by gluten in diet (celiac sprue)
• Bulky, pale, frothy, greasy stools (steatorrhea); abdominal distention,
Aatulence, weight loss, and evidence of fat-soluble vitamin
deficiencies
• Hypochromic or megaloblastic anemia; abnormal D-xylose absorption;
increased fecal fat on qilllI1titative studies
• Deficiency pattern on small bowel radiographic studies; villous
atrophy on small bowel biopsy
• Differential Diagnosis
• Crohn's disease
• Functional blind loop (especially jejunal diverticulosis)
• Intestinal tuberculosis (may be associated with celiac sprue)
• Intestinal lymphoma (may also complicate celiac sprue)
• Whipple's disease
• Pancreatic insufficiency
• Treatment
• For tropical sprue: folic acid, vitamin BI2 replacement if necessary,
tetracycline or trimethoprim-sulfamethoxazole for 1-6 months
• For celiac sprue: strict elimination of gluten from diet (ie, wheat,
rye, barley, and oat products); vitamin supplementation (especially
vitamin B12) and steroids in selected patients
• Pearl
Flat gut occurs where it comes into contact with gluten; if gluten is
introduced past the upper small bowel by nasogastric tube, the gut will
be spared.
Reference
Ryan B et at: Refractory celiac disease. Gastroenterology 2000;119:243.
+
Chapter 3 Gastrointestinal Diseases 79
Disaccharidase (Lactase) Deficiency
• Essentials of Diagnosis
• Congenital in Asians and blacks, in whom it is nearly ubiquitous;
can also be acquired temporarily after gastroenteritis of other
causes
• Symptoms vary from abdominal bloating, distention, cramps,
and flatulence to explosive diarrhea in response to disaccharide
ingestion
• Stool pH < 5.5; reducing substances present in stool
• Flat glucose response to disaccharide loading, abnormal hydrogen
breath test, or resolution of symptoms on lactose-free diet
suggests the diagnosis
• Differential Diagnosis
• Chronic mucosal malabsorptive disorders
• Irritable bowel syndrome
• Inflammatory bowel disease
• Pancreatic insufficiency
• Giardiasis
• Treatment
• Restriction of dietary lactose; usually happens by experience in
blacks from early life
• Lactase enzyme supplementation
• Maintenance of adequate nutritional and calcium intake
• Pearl
Consider this in undiagnosed diarrhea; the patient may not be aware
ofingesting lactose.
Reference
Shaw AD et a1: Lactose intolerance: problems in diagnosis and treatment. J Clin
Gastroentero! 1999;28:208.
+
80 Essentials of Diagnosis & Treatment
Whipple's Disease
• Essentials of Diagnosis
• Caused by infection with the bacillus Tropheryma whippelii
• Rare in women and blacks
• Insidious onset of fever, abdominal pain, malabsorption, arthralgias,
weight loss, symptoms of steatorrhea, polyarthritis
• Lymphadenopathy, arthritis, macular skin rash, various neurologic
findings
• Anemia, hypoalbuminemia, hypocarotenemia
• SllUlll bowel mucosal biopsy reveals characteristic foamy mononuclear
cells filled with periodic acid-Schiff (PAS) staining material;
electron microscopy shows bacilli in multiple affected organs
• Differential Diagnosis
• Celiac or tropical sprue
• Crohn's disease
• Ulcerative colitis
• Intestinal lymphoma
• Rheumatoid arthritis or HLA-B27 spondyloarthropathy
• Hyperthyroidism
• HIV infection
• Treatment
• Penicillin and streptomycin (ceftriaxone and streptomycin for
central nervous system disease) for 10-14 days followed by
trimethoprim-sulfamethoxazole (cefixime or doxycycline in
su lfonamide-allergic patients)
• Treatment for at least I year
• Pearl
Oculomasticatory myorhythmia (continuous rhythmic motion ofthe eye
muscles with mastication) or ocular-facial-skeletal myorhythmia is
Whipple's disease and nothing else.
Reference
Ramaiah C et aI: Whipple's disease. Gastroenterol Clin North Am 1998;27:683.
+
Chapter 3 Gastrointestinal Diseases 81
Intestinal Tuberculosis
• Essentials of Diagnosis
• Chronic abdominal pain, anorexia, bloating; weight loss, fever,
diarrhea, new-onset ascites in many
• Mild right lower quadrant tenderness; fistula-in-ano sometimes
seen
• Barium study may reveal mucosal ulcerations or scarring and
fibrosis with narrowing of the small or large intestine
• In peritonitis, ascitic fluid has high protein and mononuclear pleocytosis;
peritoneal biopsy with granulomas
• Complications include intestinal obstruction, hemorrhage, fistula
formation, and bacterial overgrowth with malabsorption
• Differential Diagnosis
• Carcinoma of the colon or small bowel
• Inflammatory bowel disease
• Ameboma
• Intestinal lymphoma or amyloidosis
• Ovarian or peritoneal carcinomatosis
• Mycobacterium avium-intracellulare infection
• Treatment
• Standard therapy for tuberculosis
• Pearl
Historically, many patients underwent exploratory laparotomy for suspected
small bowel obstruction; improvement inevitably ensued without
specific therapy.
Reference
Kapoor VK: Abdominal tuberculosis. Postgrad Med J 1998;74:459.
+
82 Essentials of Diagnosis & Treatment
Irritable Bowel Syndrome
• Essentials of Diagnosis
Chronic functional disorder characterized by abdominal pain,
alteration in bowel habits, constipation and diarrhea (often alternating),
dyspepsia, anxiety or depression
Variable abdominal tenderness
• Sigmoidoscopy may reveal spasm or mucous hypersecretion;
other studies normal
• Differential Diagnosis
• Inflammatory bowel disease
• Ischemic colitis
• Diverticular disease
• Peptic ulcer disease
• Pancreatitis
• Treatment
• Reassurance and explanation
• High-fiber diet with or without fiber supplements; restricting dairy
products may be helpful
• Antispasmodic agents (eg, dicyclomine, hyoscyamine, propantheline),
antidiarrheal or anticonstipation agents
Amitriptyline, serotonin selective reuptake inhibitors, and behavioral
modification with relaxation techniques helpful for some
patients
• Pearl
Irritable bowel syndrome is the most common diagnosis resulting in
office visits to a gastroenterologist; it ranks highly with primary care
providers, too.
Reference
Schmulson MW et al: Diagnostic approach to the patient with irritable bowel
syndrome. Am J Med 1999; I07(5A):20S.
+
Chapter 3 Gastrointestinal Diseases 83
Ulcerative Colitis
• Essentials of Diagnosis
• Role of personality debated; half are normal
• Low-volume diarrhea, often bloody; tenesmus and cramping
lower abdominal pain; associated with fever, weight loss, rash
• Mild abdominal tenderness, mucocutaneous lesions, erythema
nodosum or pyoderma gangrenosum
• Anemia, accelerated sedimentation rate, hypoproteinemia, absent
stool pathogens
Ragged mucosa with loss of haustral markings on barium enema;
colon involved contiguously from rectum, seldom if ever sparing
it
• Crypt abscesses on rectal mucosal biopsy
• Increased incidence of adenocarcinoma with young age at onset,
long-standing active disease, pancolitis
• Differential Diagnosis
• Bacterial, amebic, or ischemic colitis
• Diverticular disease
• Adenocarcinoma of the colon
• Benign colonic stricture
• Pseudomembranous colitis
Granulomatous colitis or Crohn's disease
• Antibiotic-associated diarrhea
• Radiation colitis or collagenous colitis
• Treatment
• Topical mesalamine or corticosteroids by enema or suppository
• Fiber supplements, lactose-free diet
• Sulfasalazine, mesalamine, or olsalazine for chronic therapy
• Mesalamine, corticosteroids, or cyclosporine for acute flares;
obtain amebic serologies before systemic steroids
• Fish oil, ciprofloxacin, nicotine may he of henefit in refractory
disease
• Colectomy for toxic megacolon unresponsive to medical therapy,
severe extracolonic manifestations, colonic malignancy or dysplasia,
or (in selected patients with long-standing disease) for
cancer prophylaxis
• Yearly colonoscopy
• Pearl
Four hepatobiliary complications: pericholangitis, chronic active
hepatitis, sclerosing cholangitis, cholangiocarcinoma.
Reference
Ghosh S et al: Ulcerative colitis. 8MJ 2000;320: 1119.
+
84 Essentials of Diagnosis & Treatment
Polyps of the Colon &Rectum
• Essentials of Diagnosis
• Discrete mass lesions arising from colonic epithelium and protruding
into the intestinal lumen; polyps may be pedunculated or
sessile
• Most patients asymptomatic; can be associated with chronic
occult blood loss
• Family history may be present
• Diagnosed by sigmoidoscopy, colonoscopy, or barium enema
• Removing polyps decreases the incidence of adenocarcinoma
• Differential Diagnosis
• Adenocarcinoma
• Radiographic artifact
• Treatment
• Surgical or endoscopic polypectomy in all cases with histologic
revIew
• Colectomy for familial polyposis or Gardner's syndrome
• Surveillance colonoscopy every 3-5 years
• Pearl
The incidence curves ofadenomalOUS polyps and carcinoma by age are
superimposable.
Reference
Kronborg 0: Colon polyps and cancer. Endoscopy 2000;32:124.
+
Chapter 3 Gastrointestinal Diseases 85
Anal Fissure
(Fissura-in-Ano, Anal Ulcer)
• Essentials of Diagnosis
• Linear disruption of the anal epithelium
• Rectal pain with defecation; bleeding and constipation
• Acute anal tenderness to digital examination
• Ulceration and stenosis of anal canal, hypertrophic anal papilla,
external skin tag on anoscopy
• Differential Diagnosis
• Rectal syphilis, tuberculosis, herpes, chlamydial infections
• Crohn's disease
• Acute monocytic leukemia
• Malignant epithelioma leukemia
• Treatment
• High-fiber diet, psyllium, bran, stool softeners, sitz baths, hydrocortisone
suppositories
• Topical nitrate therapy or botulinum toxin injection
• Lateral internal sphincterotomy if no improvement with medical
therapy
• Pearl
Unexplained cases call for white count with differential.
Reference
Janicke OM et aI: Anorectal disorders. Emerg Med Clin North Am 1996; 14:757.
-
+
86 Essentials of Diagnosis & Treatment
Acute Pancreatitis
• Essentials of Diagnosis
• Background of alcohol binge or gallstones
• Abrupt onset of epigastric pain, often with radiation to the back;
nausea, vomiting, low-grade fever, and dehydration
• Abdominal tenderness, distention
• Leukocytosis, elevated serum and urine amylase; hypocalcemia
and hemoconcentration in severe cases; hypertriglyceridemia
(> 1000 mg/dL) may be causative, likewise hypercalcemia
• Radiographic "sentinel loop" may be seen on plain films of the
abdomen, signifying localized ileus
• CT for patients highly symptomatic or for suspected abscesses
• Differential Diagnosis
• Acute cholecystitis or cholangitis
• Penetrating or perforating duodenal ulcer
• Mesenteric infarction
• Gastritis
• Nephrolithiasis
• Abdominal aortic aneurysm
• Small bowel obstruction
• Treatment
• Nasogastric suction for nausea or ileus, prompt intravenous fluid
and electrolyte replacement, analgesics, and antiemetics
• Antibiotics (imipenem) for documented infection or evidence of
necrotizing pancreatitis on CT; discontinue drugs capable of
causing the disease, eg, thiazides, corticosteroids
• Aggressive surgical debridement for sterile pancreatic necrosis
without clinical improvement with conservative measures or for
infected pancreatic necrosis
• Early endoscopic retrograde cholangiopancreatography with
sphincterotomy for pancreatitis with associated jaundice and
cholangitis resulting from choledocholithiasis
• Pearl
/n "idiopathic" pancreatitis, obtain more history from someone other
than the patient. You can be sure alcohol is in the picture.
Reference
Janicke DM et al: Anorectal disorders. Emerg Med Clin North Am 1996;14:757.
+
Chapter 3 Gastrointestinal Diseases 87
Chronic Pancreatitis
• Essentials of Diagnosis
• Persistent or recurrent abdominal pain
• Pancreatic calcification by radiographic study
• Pancreatic insufficiency with malabsorption and diabetes in onethird
of patients
• Occurs in patients with alcoholism (most common), hereditary
pancreatitis, or untreated hyperparathyroidism; or after abdominal
trauma
• Diagnostic studies include endoscopic retrograde cholangiopancreatography
(beading of pancreatic duct with ectatic side branches),
endoscopic ultrasound (stippling or stranding of parenchyma with
ductal dilation or thickening), magnetic resonance cholangiopancreatography,
and an abnormal secretin pancreatic stimulation test
• Differential Diagnosis
• Diabetes mellitus
• Malabsorption due to other causes
• Intractable duodenal ulcer
• Carcinoma of the pancreas
Gallstones
Irritable bowel syndrome
• Treatment
• Low-fat diet, pancreatic enzyme supplements, avoidance of
alcohol
Pain management includes opioids and amitriptyline
Endoscopic sphincterotomy and pancreatic duct stenting as well
as endoscopic ultrasound-guided celiac block for pain management
have yielded disappointing results
• Treatment of hyperlipidemia if present
• Intravenous fluid and electrolyte replacement for acute exacerhations
• Surgical therapy to restore free flow of bile or to treat intractable
pain
• Pearl
Alcohol and trauma are the causes of chronic relapsing pancreatitis.
As always, the history will tell the story.
Reference
Apte MV et al: Chronic pancreatitis: complications and management. J Clin
Gastroenterol 1999;29:225.
+
88 Essentials of Diagnosis & Treatment
Clostridium difficile (Pseudomembranous) Colitis
• Essentials of Diagnosis
• Profuse watery, green, foul-smelling, or bloody diarrhea
• Cramping abdominal pain
• Fecal leukocytes present in over half of patients
• Fevers, marked abdominal tenderness, leukocytosis, hypovolemia,
dehydration, and hypoalbuminemia are common
• History of antibiotic use (especially penicillin family antibiotics
and cJindamycin)
• Many cases may be asymptomatic or associated with minimal
symptoms
• Diagnosis confirmed by positive stool antigen test or via sigmoidoscopy
or colonoscopy.
• Differential Diagnosis
• Antibiotic-associated diarrhea (without C difficile or pseudomembranous
colitis)
• Other bacterial diarrheas
• Inflammatory bowel disease
• Parasitic (amebiasis) and viral (cytomegalovirus) causes of diarrhea
and colitis
• Treatment
• Discontinue offending antibiotic therapy
• Replacement of fluid and electrolyte losses
• Oral metronidazole, with vancomycin reserved for metronidazoleresistant
cases or critically ill patients; treatment is for 10-14 days
• Surgical therapy is needed rarely (1-3%) for severe cases with
megacolon or impending perforation
• Avoid opioids and antidiarrheal agents
• Pearl
The cause ofthe highest benign white count in all ofmedicine save pertussis.
Reference
Taege AJ et al: Clostridium difficite diarrhea and colitis: a clinical overview.
Cleve Clin J Med 1999;66:503.
+
Chapter 3 Gastrointestinal Diseases 89
Acute Colonic Pseudo-Obstruction
(Ogilvie's Syndrome)
• Essentials of Diagnosis
• Often seen in elderly hospitalized patients
• Associated with a history of trauma, fractures, cardiac disease,
infection, or the use of opioids, antidepressants, and anticholinergics
• Often detected as a distended, tympanitic abdomen with abdominal
x-ray revealing gross colonic dilation (cecum> 10 em), scant
air-Auid levels, a gradual transition to collapsed bowel, and air
and stool present in the rectum
May mimic true obstruction, and obstruction should be evaluated
with radiologic studies using diatrizoate (Hypaque) enema
• Fevers, marked abdominal tenderness, leukocytosis, and acidosis
may be present in advanced cases with impending perforation
• Differential Diagnosis
• Mechanical obstruction
• Toxic megacolon
• Chronic intestinal pseudo-obstruction
• Treatment
• Cessation of oral intake, nasogastric and rectal suctioning, intravenous
fluids
• Correction of electrolyte abnormalities (Ca2+, Mg2+, K+)
• Discontinue offending medications and treat underlying infections
• Frequent enemas (tap water) and patient repositioning may be of
benefit
• Neostigmine (2 mg intravenously) in appropriately selected
patients
• Colonoscopic decompression for patients failing neostigmine or
in whom neostigmine therapy is contraindicated
• Surgical consultation (for tube cecostomy) for patients with peritoneal
signs or impending perforation
• Pearl
Many patients with this disorder have surprisingly unimpressive examinations.
Sequential abdominalfilms in high-risk leU patients are prudent
irrespective ofsymptoms.
Reference
Oi Lorenzo C: Pseudo-obstruction: current approaches. Gastroentero!ogyI999;
116:980.
-
4
Hepatobiliary Disorders
Acute Viral Hepatitis
• Essentials of Diagnosis
• Anorexia, nausea, vomiting, malaise, symptoms of flu-like syndrome,
arthralgias, and aversion to smoking
• Jaundice, fever, chi Us; enlarged, tender liver
• Normal to low white cell count; abnormal liver function studies
(ALT > AST); serologic tests for hepatitis A (lgM antibody),
hepatitis B (HBsAg), or hepatitis C (antibody) may be positive
• Liver biopsy shows characteristic hepatocellular necrosis and
mononuclear infiltrates
• Hepatitis A: oral-fecal transmission, short incubation period;
good prognosis, but rare cases of fulminant hepatic failure
• Hepatitis B and hepatitis C: parenteral transmission, longer incubation
period, progression to chronic disease more likely
• Differential Diagnosis
• Alcoholic hepatitis
• Leptospirosis
• Secondary syphilis
• Qfever
• Choledocholithiasis
• Carcinoma of the pancreas
• ChoJestatic jaundice secondary to drugs
• Acetaminophen toxicity
• Hepatic vein thrombosis
• Treatment
• Supportive care
• Avoidance of hepatotoxins: alcohol, acetaminophen
• Pearl
Hepatitis A is the only viral hepatitis causing spiking fevers.
Reference
Sjogren MH: Serologic diagnosis of viral hepatitis. Med Clin North Am 1996;
80:929. [PMID: 8804369]
90
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 4 Hepatobiliary Disorders 91
+
Chronic Viral Hepatitis
• Essentials of Diagnosis
• Fatigue, right upper quadrant discomfort, arthralgias, depression,
nausea, anorexia
• In advanced cases (cirrhosis): jaundice, variceal bleeding, encephalopathy,
ascites, spontaneous bacterial peritonitis, and hepatocellular
carcinoma
• Persistent elevation in ALT (> 6 months)
• In hepatitis B, positive hepatitis B DNA with HBeAg present
• In hepatitis C, positive hepatitis C RNA
• Differential Diagnosis
• Alcoholic cirrhosis
• Metabolic liver disorders, eg, Wilson's disease, hemochromatosis
• Autoimmune hepatitis
• Cholestatic jaundice secondary to drugs
• Treatment
• Avoidance of alcohol, acetaminophen
• Interferon alfa or lamivudine for patients with chronic active hepatitis
B and interferon alfa and ribavirin for symptomatic patients
with hepatitis C
• Liver transplantation for advanced disease
• Pearl
Hepatitis C is the most common reason for liver transplantation.
Reference
8erenguer M et al: Hepatitis. Advances in antiviral therapy for hepatitis. Lancet
1998;352(SuppI4):SIVI5. [PMID: 9873162]
+
92 Essentials of Diagnosis & Treatment
Autoimmune Hepatitis
• Essentials of Diagnosis
• Insidious onset; usually affects young women
• Fatigue, anorexia, arthralgias; dark urine; light stools in some
• Jaundice, spider angiomas, hepatomegaly, acne, hirsutism
• Abnormal liver function tests, most notably increased aminotransferases,
polyclonal gammopathy
• Associated with arthritis, thyroiditis, nephritis, Coombs-positive
hemolytic anemia
• ANA or anti-smooth muscle antibody-positive
• Patients may develop cirrhosis, predicted by biopsy features of
chronic active hepatitis
• Differential Diagnosis
• Chronic viral hepatitis
• Sclerosing cholangitis
• Primary biliary cirrhosis
• Wilson's disease
• Hemochromatosis
• Treatment
• General supportive measures (including exercise, calcium, and
hormonal therapy to prevent osteoporosis)
• Prednisone with or without azathioprine
• Liver transplantation for decompensated cirrhosis
• Pearl
Spider angiomas never occur below the waist.
Reference
Czaja AJ: The variant forms of autoimmune hepatitis. Ann Intern Med 1996;
125:588. [PMlD: 8815758]
+
Chapter 4 Hepatobiliary Disorders 93
Alcoholic Hepatitis
• Essentials of Diagnosis
• Onset usually after years of alcohol intake; anorexia, nausea,
abdominal pain
• Fever, jaundice, tender hepatomegaly, ascites, encephalopathy
• Macrocytic anemia, leukocytosis with left shift, thrombocytopenia,
abnormal liver function tests (AST> ALT, increased bilirubin,
prolonged prothrombin time), hypergammaglobulinemia;
AST rarely exceeds 300 units/L despite severity of illness
• Liver biopsy confirms diagnosis
• Differential Diagnosis
• Cholecystitis, cholelithiasis
• Cirrhosis due to other causes
• Non-alcoholic fatty liver
• Viral hepatitis
• Drug-induced hepatitis
• Treatment
• General supportive measures, withdrawal of alcohol, avoidance
of hepatotoxins (especially acetaminophen)
• Methylprednisolone (32 mg/d for 4 weeks) may be beneficial in
severe disease when discriminant function (4.6 [PT - control] +
bilirubin [mg/dL]) is> 32
• Pearl
Acute alcoholic hepatitis can be indistinguishable from antle cholecystitis
with or without cholangitis. This is the most useful application
ofabdominal ultrasOlmd.
Reference
Hill DB et aJ: Alcoholic liver disease. Treatment strategies for the potentially
reversible stages. Postgrad Med 1998;103:26I.lPMID: 9553600j
+
94 Essentials of Diagnosis & Treatment
Cirrhosis
• Essentials of Diagnosis
• The outcome of many types of hepatitis-viral, toxic, immune,
and metabolic
• Insidious onset of malaise, weight loss, increasing abdominal girth,
erectile dysfunction in men
• Jaundice, spider angiomas, palpable firm hepatomegaly, palmar
erythema, Dupuytren's contractures, gynecomastia, ascites, edema,
encephalopathy with asterixis
Macrocytic anemia, thrombocytopenia, abnormal liver function
(increased prothrombin time, hypoalbuminemia)
• Biopsy diagnostic with micro- or macronodular fibrosis
• Complications include esophageal or gastric varices, gastrointestinal
bleeding, spontaneous bacterial peritonitis, encephalopathy,
hepatorenal syndrome
• Differential Diagnosis
• Congestive heart failure
• Constrictive pericarditis
• Hemochromatosis
• Primary biliary cirrhosis
• Wilson's disease
• Schistosomiasis
• Nephrotic syndrome
• Hypothyroidism
• Treatment
• Supportive care, abstinence from alcohol, vitamin supplementation
• Beta-blockers in patients with established varices
• Diuretics or large-volume paracenteses for ascites and edema
• Antibiotic treatment and, debatably, prophylaxis for spontaneous
bacterial peritonitis
• Lactulose for encephalopathy
• Transjugular intrahepatic ponosystemic shunt for bleeding esophageal
varices or refractory ascites
• Liver transplantation in selected cases
• Pearl
Hepatitis A never causes cirrhosis.
Reference
Menon KV et al: Managing the complications of cirrhosis. Mayo Clin Proc
2000;75:501. [PMID: 10807079]
Chapter 4 Hepatobiliary Disorders 95
+
Primary Biliary Cirrhosis
• Essentials of Diagnosis
• Usually affects women aged 40-60 with the insidious onset of
pruritus, jaundice, and hepatomegaly
• Hepatomegaly in 70% with splenomegaly in 35%
• Malabsorption, xanthomatous neuropathy, osteomalacia, and portal
hypertension may be complications
• Increased alkaline phosphatase, cholesterol, bilirubin; positive
antimitochondrial antibody in 95%
• Differential Diagnosis
• Chronic biliary tract obstruction, ie, cholelithiasis-related stricture
• Bile duct carcinoma
• Inflammatory bowel disease complicated by cholestatic liver
disease
• Sarcoidosis
• Sclerosing cholangitis
• Drug-induced cholestasis
• Treatment
• Cholestyramine, colestipol, or rifampin for pruritus
• Calcium and supplementation with vitamins A, D, E, and K
• Ursodeoxycholic acid, colchicine, or methotrexate may be helpful
• Liver transplant for refractory cirrhosis
• Pearl
The perfect disease for cure by tram,plantation: no virus, no malignancy
in explant.
Reference
Neuberger J: Primary biliary cirrhosis. Lancet 1997;350:875. [PMID: 9310614]
+
96 Essentials of Diagnosis & Treatment
Hepatic Vein Obstruction (Budd-Chiari Syndrome)
• Essentials of Diagnosis
• Spectrum of disorders characterized by occlusion of the hepatic
veins from a variety of causes
• Acute or chronic onset of tender, painful hepatic enlargement,
jaundice, splenomegaly, and ascites
• Liver scintigraphy may show a prominent caudate lobe since its
venous drainage may not be occluded; liver biopsy reveals characteristic
central lobular congestion
• Doppler ultrasound or venography demonstrates occlusion of the
hepatic veins
• Associations include caval webs, polycythemia, right-sided heart
failure, malignancy, "bush teas" (pyrrolizidine alkaloids), paroxysmal
nocturnal hemoglobinuria, birth control pills, pregnancy,
hypercoagulable states
• Differential Diagnosis
• Cirrhosis
• Constrictive pericarditis
• Restrictive or dilated cardiomyopathy
• Metastatic disease involving the liver
• Granulomatous liver disease
• Treatment
• Treatment of complications, eg, ascites, encephalopathy
• Lifelong anticoagulation or treatment of underlying disease
• Portacaval, mesocaval, or mesoatrial shunt may be required
• Transvenous intravascular portosystemic shunt may be considered
in noncirrhotic patients
• Liver transplantation for severe hepatocellular dysfunction
• Pearl
"Idiopathic" Budd-Chiari syndrome has been shown to be caused in
many cases by subclinical myeloproliferative diseases.
Reference
Mahmoud A et al: New approaches to the Budd-Chiari syndrome. J Gastroenteral
Hepatol 1996;11: 1121. [PMID: 9034920]
+
Chapter 4 Hepatobiliary Disorders 97
Pyogenic Hepatic Abscess
• Essentials of Diagnosis
• Right-sided or midabdominal pain, anorexia, nausea; weight loss,
pleuritic chest pain, cough
• Fever, jaundice, right upper quadrant tenderness, weight loss,
pleuritic chest pain, cough
• Leukocytosis with left shift; nonspecific abnormalities of liver
function studies
• Most common organisms are Escherichia coli, Proteus vulgaris,
Enterobacter aerogenes. and anaerobic species
• Elevated right hemidiaphragm by radiography; ultrasound, CT
scan, or liver scan demonstrates intrahepatic defect
• Predisposing factors: malignancy, recent endoscopy or surgery, diabetes,
Crahn's disease, diverticulitis, appendicitis, recent trauma
• Differential Diagnosis
• Amebic hepatic abscess
• Acute hepatitis
• Right lower lobe pneumonia
• Cholelithiasis. cholecystitis
Appendicitis
• Treatment
• Antibiotics with coverage of gram-negative organisms and
anaerobes
• Needle or surgical drainage for cases refractory to medical management
• Pearl
The classic triad offever, jaundice, and hepatomegaly is found in less
than 10% ofcases.
Reference
Ch Yu S et al: Pyogenic liver abscess: treatment with needle aspiration. Clin
Radiol 1997;52:912. [PMlD: 9413964]
+
98 Essentials of Diagnosis & Treatment
Amebic Hepatic Abscess
• Essentials of Diagnosis
• Right-sided abdominal pain, right pleuritic chest pain; preceding
or concurrent diarrheal illness in minority
• History of travel to endemic region
• Fever, tender palpable liver ("punch" tenderness), localized intercostal
tenderness
• Anemia, leukocytosis with left shift, nonspecific Ii ver test abnormalities
• Positive serologic tests for Entamoeba histolytica in over 95% of
patients, though may be initially nondiagnostic
• Increased right hemidiaphragm by radiography; ultrasound, CT
scan, or liver scan demonstrates location and number of lesions
• Differential Diagnosis
• Pyogenic abscess
• Acute hepatitis
• Right lower lobe pneumonia
• Cholelithiasis, cholecystitis
• Appendicitis
• Treatment
• Metronidazole drug of choice; repeated courses occasionally
necessary
• Percutaneous needle aspiration for toxic patient
• Oral course of luminal amebicides (iodoquinol, paromomycin
sulfate) following acute therapy to eradicate intestinal cyst phase
• Pearl
Amebic liver abscess presents with amebic colitis in only 10% ofcases.
Aspiration ofabscess reveals odorless yellow to dark brown "anchovy
paste" material.
Reference
Fujihara T et al: Amebic liver abscess. J Gastroenterol 1996;31 :659. [PMID:
8887031 ]
+
Chapter 4 Hepatobiliary Disorders 99
Cholelithiasis (Gallstones)
• Essentials of Diagnosis
• Frequently asymptomatic but may be associated with recurrent
bouts of right-sided or midepigastric pain and nausea or vomiting
after eating
• Ultrasound, CT scan, and plain films demonstrate stones within
the gallbladder
• Increased incidence with female gender, chronic hemolysis, obesity,
Native American origin, inflammatory bowel disease, diabetes
mellitus, pregnancy, hypercholesterolemia
• Differential Diagnosis
• Acute cholecystitis
• Acute pancreatitis
• Peptic ulcer disease
• Acute appendicitis
• Acute hepatitis
• Right lower lobe pneumonia
• Myocardial infarction
• Radicular pain in T6-TlO dennatome
• Treatment
• Laparoscopic or open cholecystectomy for symptomatic patients
only
• Bile salts (cheno- and ursodeoxycholic acid) may cause dissolution
of cholesterol stones
• Lithotripsy with concomitant bile salts administration may be
successful
• Pearl
/n a patient with right upper quadrant densities on a plain film of the
abdomen associated with hyperchromia and microcytosis. consider
hereditary spherocytosis with premature cholelithiasis due to lifelong
hemolysis.
Reference
Agrawal Set al: Gallstones, from gallbladder to gut. Management options for
diverse complications. Postgrad Med 2000;108: 143. [PMID: 11004941]
+
100 Essentials of Diagnosis & Treatment
Choledocholithiasis
• Essentials of Diagnosis
• Often a history of biliary tract disease; episodic attacks of right
abdominal or epigastric pain that may radiate to the right scapula
or shoulder; occasionally painless jaundice
• Pain, fever, and jaundice (Charcot's triad); associated with nausea,
vomiting, hypothermia, shock, and leukocytosis with a left shift
• Elevated serum amylase and liver function tests, especially bilirubin
and alkaline phosphatase
• Abdominal imaging studies may reveal gallstones
• Ultrasound or CT scan shows dilated biliary tree
• Endoscopic retrograde cholangiopancreatography (ERCP) or
magnetic resonance cholangiopancreatography (MRCP) localizes
the degree and location of obstruction
• Differential Diagnosis
• Carcinoma of the pancreas, ampulla of Vater, or common duct
• Acute hepatitis
• Bi liary stricture
• Drug-induced cholestatic jaundice
• Pancreatitis
• Other septic syndromes
• Treatment
• Intravenous broad-spectrum antibiotics
• Endoscopic papillotomy and stone extraction followed by laparoscopic
or open cholecystectomy
• A T tube may be placed in the common duct to decompress it for
at least 7-8 postoperative days
• Pearl
Although choledocholithiasis is often asymptomatic, onset of septic
shock may occur within hours. The sun should never set on this diagnosis.
Reference
Soetikno RM et aI: Endoscopic management of choledocholithiasis. ] Clin Gastroenterol
1998;27:296. [PMlD: 9855257]
Chapter 4 Hepatobiliary Disorders 101
Sclerosing Cholangitis
+
• Essentials of Diagnosis
• Progressively obstructive jaundice, pruritus, malaise, anorexia,
and indigestion, most common in young men aged 20-40 years
• Two-thirds of cases have associated ulcerative colitis
• Positive antineutrophil cytoplasmic antibody found in 70%; elevated
total bilirubin and alkaline phosphatase common
Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates
thick or narrowed biliary ductal system
Absence of previous biliary stones, biliary surgery, congenital
abnormalities, biliary cirrhosis, and cholangiocarcinoma necessary
to make the diagnosis
• Differential Diagnosis
• Choledocholithiasis
• Drug-induced cholestasis
• Carcinoma of pancreas or biliary tree
• Hepatitis due to any cause
Clonorchis sinensis infection
• Treatment
• At present, no specific medical therapy has been shown to have a
major impact on the prevention of complications or survival
Ursodeoxycholic acid may improve liver function tests but does
not alter natural history
Stenting or balloon dilation of localized strictures by ERCP
• Liver transplantation for decompensated disease
• Pearl
Most sclerosing cholangitis is seen in ulcerative colitis, but most ulcerative
colitis is not complicated by sclerosing cholangitis.
Reference
Angulo Pet al: Primary sclerosing cholangitis. Hepatology 1999;30:325. [PM ID:
10385674]
+
102 Essentials of Diagnosis &Treatment
Variceal Bleeding
• Essentials of Diagnosis
• Sudden, painless large-volume episode of hematemesis with
melena or hematochezia typical
Antecedent history of liver disease and stigmas of liver disease or
ponal hypertension on physical examination
• A hepatic portal venous pressure gradient of~12 mm Hg is generally
necessary for variceal bleeding
• Fifty percent of patients with alcoholic cirrhosis will present with
esophageal varices within 2 years of diagnosis
• A 30-50% risk of death with each episode
• Differential Diagnosis
• Mallory-Weiss tear
• Alcoholic gastritis
• Peptic ulcer disease
• Esophagitis
• Bleeding from ponal hypenensive gastropathy
• Treatment
• Appropriate resuscitation (intravenous resuscitation, correction
of coagulopathy, blood transfusions, airway protection, antibiotic
therapy for spontaneous bacterial peritonitis prophylaxis)
• Intravenous octreotide (100 ~g bolus, 50 ~g/h drip)
• Urgent endoscopic evaluation and treatment with band ligation
or sclerotherapy; less successful in gastric varices
• Balloon tamponade (Minnesota-Sengstaken-Blakemore) as a
temporizing measure or for endoscopic failures
• Transjugular intrahepatic ponosystemic shunt (TIPS) or shunt
surgery for refractory cases of esophageal or gastric varices
Liver transplantation for appropriate candidates with recurrent
bleeding episodes
Prophylaxis of recurrent hleeding with endoscopic (hand ligation)
and pharmacologic therapy (propranolol, nadolol)
• Pearl
In a patient with any possible lifetime exposure, eg, a person born in
Puerto Rico with no other liver disease, consider schistosomiasiseven
if there has been no visit to the endemic area for over 20 years.
Reference
Luketic VA et al: Esophageal varices. I. Clinical presentation, medical therapy,
and endoscopic therapy. Gastroenterol Clin North Am 2000;29:337. [PMID:
10836186]
Chapter 4 Hepatobiliary Disorders 103
Ascites
+
• Essentials of Diagnosis
• Usually associated with liver disease; but heart or kidney disease
should also be sought
• Evidence of shifting dullness, bulging flanks
• Paracentesis for new-onset ascites or symptoms suggestive of
spontaneous bacterial peritonitis
• Fluid sent for cell count, albumin, total protein; glucose, amylase,
LDH, bacterial stains, cytology examination, and triglycerides in
some
• Serum-ascites albumin gradient 2': 1.1 g/dL is virtually diagnostic
of portal hypertension
• > 250 neutrophils/llL with a percentage greater than 50% characteristic
of infection
• Differential Diagnosis
• Chronic liver disease (80-85% of all cases)
• Malignancy-related (10%)
• Cardiac failure (3%)
• Tuberculosis
• Dialysis-related
• Pancreatic
• Lymphatic tear (chylous)
• Treatment
Treat as follows for ascites due to portal hypertension:
Sodium restriction « 2g/d)
Fluid restriction if serum sodium < 120 mmol/L
Diuretics: usually spironolactone and furosemide
Large-volume paracentesis (4-6 L) for tense or refractory ascites
with albumin replacement (6-10 giL)
Transjugular intrahepatic portosystemic shunt (TIPS) or surgical
shunting in refractory cases
Patients with spontaneous bacterial peritonitis treated for 5 days
with a third-generation cephalosporin (eg, cefotaxirne)
Spontaneous bacterial peritonitis prophylaxis (with norfloxacin
or trimethoprim-sulfisoxazole) for patients with spontaneous bacterial
peritonitis, gastrointestinal hemorrhage, or low-protein
ascites « 1.5 g/dL)
• Pearl
Once spontaneous bacterial peritonitis occurs, liver transplant may be
the only intervention that prolongs life.
Reference
Menon KY et al: Managing the complications of cirrhosis. Mayo Clin Proc
2000;75:50 I. [PMlD: 10807079]
+
104 Essentials of Diagnosis & Treatment
Hepatic Encephalopathy
• Essentials of Diagnosis
• Neurologic and psychiatric abnormalities resulting from liver
dysfunction due to acute liver failure, cirrhosis, or major noncirrhotic
portosystemic shunting
• Diagnosis requires history and physical examination suggestive
of liver disease or portosystemic shunting
• Clinical manifestations range from mild confusion, personality
changes, and sleep disturbances (stage I) to coma (stage IV)
Asterixis, hyperreAexia, muscular rigidity, extensor plantar response,
parkinsonian features, immobile facies, slow and monotonous
speech
• Often triggered by gastrointestinal bleeding, infection, lactulose
noncompliance, dietary protein overload, hypokalemia
• Differential Diagnosis
• Systemic or central nervous system sepsis
• Hypoxia or hypercapnia
• Acidosis
Uremia
• Medication
Postictal confusion
• Wemicke-Korsakoff syndrome
Acute liver failure (cerebral edema or hypoglycemia)
• Delirium tremens
• Hyponatremia
• Treatment
• Identify and treat precipitating factors listed above
• Lactulose, 30-60 mL by mouth or nasogastric tube every 2 hours
until bowel movements occur; titrate to maintain two or three loose
stools per day
• Flumazenil of temporary henefit
• Dietary protein restriction « 70 g/d but> 40 g/d)
• Liver transplantation for chronic hepatic encephalopathy
• Pearl
In a stable cirrhotic with encephalopathy and none of the above precipitants,
hepatocellular carcinoma is the most likely explanation.
Reference
Butterworth RF: Complications of cirrhosis 111. Hepatic encephalopathy. J Hepato12000;
32(1 Suppl):171. [PMID: 10728803]
Chapter 4 Hepatobiliary Disorders 105
Hepatocellular Carcinoma
• Essentials of Diagnosis
• One of the world's most common visceral tumors
• Hepatitis B, hepatitis C, alcoholic cirrhosis, hemochromatosis
among the important risk factors
• Symptoms may not help, as they are similar to those of underlying
liver disease
• Even a palpable mass can be confusing because of regenerating
nodules
• Edema due to inferior vena cava invasion
• Elevated-sometimes markedly-alpha-fetoprotein in some but
not all; characteristic arterial phase helical CT scan
• Differential Diagnosis
• Metastatic primary of other source
• Regenerating nodule
• Treatment
• Surgical resection if uninvolved liver not cirrhotic (as in virus
carriers) and only one lobe involved
• Transplant in highly selected patients
• Pearl
A normal hematocrit in cirrhosis suggests this diagnosis; the tumor
may manufacture erythropoietin, and most cirrhotics are anemic.
Reference
Bergsland EK et al: Hepatocellular carcinoma. Curr Opin OncoI2000;12:357.
[PMJD: 10888422]
5
Hematologic Diseases
Iron Deficiency Anemia
• Essentials of Diagnosis
• Lassitude; in children under age 2, poor muscle tone, delayed
motor development
Pallor, cheilosis, and koilonychia
• Hypochromic microcytic red cells late in disease; indices normal
early
• Serum iron low, total iron-binding capacity increased; absent marrow
iron; serum ferritin < 15 ng/mL classically, but concomitant
illness may elevate it
• Newer tests include increased serum soluble transferrin receptor
and transferrin receptor: log ferritin ratio
• Occult blood loss invariably causative in adults; malabsorption
or dietary insufficiency rarely if ever causes deficiency
• Differential Diagnosis
• Anemia of chronic disease
• Thalassemia
• Sideroblastic anemias, including lead intoxication
• Treatment
• Oral ferrous sulfate or ferrous gluconate three times daily for
6-12 months
• Parenteral iron dextran for selected patients with severe, clinically
significant iron deficiency with continuing chronic blood loss
• Evaluation for occult blood loss
• Pearl
Remember iron deficiency as a treatable cause ofobesity; ice cream
craving is one ofmany associated picas.
Reference
Frewin Ret al: ABC of clinical haematology. Iron deficiency anaemia. BM};
1997;314:360. [PMID: 9040336J
106
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 5 Hematologic Diseases 107
Anemia of Chronic Disease
+
• Essentials of Diagnosis
• Known chronic disease, particularly inflammatory; symptoms and
signs usually those of responsible disease
• Modest anemia (Hct ~ 25%); red cells normal morphologically
but may be slightly microcytic
• Low serum iron with normal or low total iron-binding capacity,
normal or high serum ferritin, normal or increased bone marrow
iron stores, low soluble transferrin receptor and soluble transferrin
receptor: log ferritin ratio
• Differential Diagnosis
• Iron deficiency anemia
• Sideroblastic anemia
• Thalassemia
• Treatment
• None usually necessary
• Red blood cell transfusions for symptomatic anemia, recombinant
erythropoietin (epoetin alfa) in patients with associated renal
disease
• Pearl
In anemia ofchronic disease, the hemoglobin and hematocrit should
not fall below 60% ofbaseline; if lower, some other cause ofanemia
is present.
Reference
Spivak JL: The blood in systemic disorders. Lancet 2000;355: 1707. [PMID:
10905258]
+
108 Essentials of Diagnosis & Treatment
Disseminated Intravascular Coagulation
• Essentials of Diagnosis
• Evidence of abnormal bleeding or clotting, usually in a critically
ill patient
• Occurs as a result of activation and consumption of clotting and
antithrombotic factors due to severe stressors such as sepsis, bums,
massive hemorrhage
• May occur in chronic, indolent fonn, usually associated with
malignancy
• Anemia, thrombocytopenia, elevated prothrombin time and, later,
partial thromboplastin time, low fibrinogen, elevated fibrin degradation
products and fibrin o-dimers
• Differential Diagnosis
• Severe liver disease
• Thrombotic thrombocytopenic purpura
• Vitamin K deficiency
• Other microangiopathic hemolytic anemias (eg, prosthetic heart
valve)
• Sepsis-induced thrombocytopenia or anemia
• Heparin-induced thrombocytopenia
• Treatment
• Treat underlying disorder
• Replacement of consumed blood factors with fresh frozen plasma,
cryoprecipitate, and potentially antithrombin fU
• Heparin in selected cases, particularly acute promyelocytic
leukemia
• Antifibrinolytic therapy (aminocaproic acid or tranexarnic acid)
for refractory bleeding, but only in presence of heparin therapy
• Pearl
Remember that platelets andfibrinogen may be normal in chronic DIe.
Reference
Levi Met al: Disseminated intravascular coagulation. N Engl J Med 1999;
341:586. [PMJD: 10451465]
Chapter 5 Hematologic Diseases 109
+
Thrombotic Thrombocytopenic Purpura (TIP)
• Essentials of Diagnosis
• Petechial rash, mucosal bleeding, fever, altered mental status,
renal failure; many cases in HIV infection
• Laboratory reports are notable for anemia, dramatically elevated
LDH, normal prothrombin and partial thromboplastin times,
fibrin degradation products, and thrombocytopenia
• Most cases probably related to acquired inhibitor of von Willebrand
factor-cleaving protease; may also be secondary to drugs, chemotherapy,
or cancer
• Demonstrating presence or decreased activity of vWF-cleaving
protease inhibitor may be diagnostic, but tests not commonly
available
• Differential Diagnosis
• Disseminated intravascular coagulation
• Preeclampsia-eclampsia
• Other microangiopathic hemolytic anemias
• Hemolytic-uremic syndrome
• Treatment
• Immediate plasmapheresis
• Fresh-frozen plasma infusions help if plasmapheresis not readily
available
• Splenectomy and immunosuppressive or cytotoxic medications
for refractory cases
• Pearl
A previously rare disease which doubled in incidence during the AiDS
epidemic.
Reference
George IN: How I treat patients with thrombotic thrombocytopenic purpurahemolytic
uremic syndrome. Blood 2000;96:1223. [PMID: 10942361]
+
110 Essentials of Diagnosis & Treatment
Hemolytic-Uremic Syndrome
• Essentials of Diagnosis
• Petechial rash, hypertension, acute-to-subacute renal failure
• Often preceded by gastroenteritis or exposure to offending medication
• Frequently associated with antecedent campylobacter infection
(may be very mild to occult)
• Laboratory reports notable for thrombocytopenia, anemia, renal
failure, elevated LDH, normal prothrombin time and partial
thromboplastin time as well as fibrin and fibrinogen degeneration
products
• Differential Diagnosis
• Disseminated intravascular coagulation
• Thrombotic thrombocytopenic purpura
• Pre-eclampsia--eclampsia
• Other microangiopathic hemolytic anemias
• Treatment
• Tn children, disease is most often self-limited and managed with
supportive care
• In adults, stop potentially offending drugs
• Plasmapheresis for refractory cases
• Pearl
Many childhood cases are precipitated by E coli 0157:H7 infection.
Reference
van Gorp EC et al: Review: infectious diseases and coagulation disorders. J
Infect Dis 1999; 180: 176. [PMID: 10353876]
Chapter 5 Hematologic Diseases 111
+
Autoimmune Hemolytic Anemia
• Essentials of Diagnosis
• Acquired anemia caused by IgG autoantibody
• Fatigue, malaise in many; occasional abdominal or back pain
• Pallor, jaundice, but palpable spleen uncommon
• Persistent anemia with microspherocytes and reticulocytosis; elevated
indirect bilirubin and serum LDH
• Positive Coombs (direct antiglobulin) test
• Various drugs, underlying autoimmune or lymphoproliferative
disorder may be causative
• Differential Diagnosis
• Hemoglobinopathy
• Hereditary spherocytosis
• Nonspherocytic hemolytic anemia
• Sideroblastic anemia
• Cold agglutinin disease
• Megaloblastic anemia
• Treatment
• High-dosage steroids
• Intravenous immune globulin, or plasmapheresis in severe cases
• Cross-match difficult because of autoantibodies, so least incompatible
blood used
• Splenectomy for refractory or recurrent cases
• More intensive immunosuppressive regimens available for refractory
cases after splenectomy
• Pearl
When therapeutic splenectomy is being contemplated, give prophylactic
pneumococcal vaccine.
Reference
Smith LA: Autoimmune hemolytic anemias: characteristics and classification.
Clin Lab Sci 1999;12:110. [PMTD: 10387488]
+
112 Essentials of Diagnosis & Treatment
Drug-Induced Hemolytic Anemia
• Essentials of Diagnosis
• Immune hemolytic anemia due to host antibody recognition of
drug and red blood cell membrane
• Acute to subacute onset; elevated LDH, hyperbilirubinemia,
reticulocytosis
• Rarely, fulminant presentation with laboratory abnormalities as
noted plus hemoglobinemia-hemoglobinuria, renal failure, and
hemodynamic instability
• Positive Coombs test with patient's blood; study using reagent
red blood cells positive only in presence of offending drug
• Differential Diagnosis
• Autoimmune hemolytic anemia
• Microangiopathic hemolytic anemia (eg, disseminated intravascular
coagulation, thrombotic thrombocytopenic purpura)
• Delayed transfusion-related hemolysis
• Blood loss
• Treatment
• Discontinue offending drug
• Plasmapheresis for severe cases, especially if drug has long serum
half-life
• Intravenous immune globulin, steroids potentially of benefit
• Pearl
An annoying prospect in an internal medicine patient: since many drugs
can cause it and since typical patients are taking many dntgs, the only
way to be sure is to peel off the dntgs one by one until improvement is
noted.
Reference
Wright MS: Drug-induced hemolytic anemias: increasing complications to therapeutic
interventions. Clin Lab Sci 1999;12:115. [PMID: 10387489]
Chapter 5 Hematologic Diseases 113
+
Hemolytic Transfusion Reaction
• Essentials of Diagnosis
• Chills and fever during blood transfusion
• Back, chest pain; dark urine
• Associated with vascular collapse, renal failure, and disseminated
intravascular coagulation
• Hemolysis, hemoglobinuria, and severe anemia
• Differential Diagnosis
• Leukoagglutination reaction
• IgA deficiency with anaphylactic transfusion reaction
• Myocardial infarction
• Acute abdomen due to other causes
• Pyelonephritis
• Bacteremia due to contaminated blood product
• Treatment
• Stop transfusion immediately
• Hydration and intravenous mannitol to prevent renal failure
• Pearl
Any adverse clinical event during transfusion should be considered and
evaluated as a hemolytic reaction.
Reference
Sloop GD et al: Complications of blood transfusion. How to recognize and
respond to noninfectious reactions. Postgrad Med 1995;98: 159. [PMID:
7603944]
+
114 Essentials of Diagnosis & Treatment
Hereditary Spherocytosis
• Essentials of Diagnosis
• Chronic hemolytic anemia of variable severity, often with exacerbations
during coi ncident iUnesses
• Malaise, abdominal discomfort in symptomatic patients
• Jaundice, splenomegaly in severely affected patients
• Variable anemia with spherocytosis and reticulocytosis; elevated
MCHC; increased osmotic fragility test and increased red cell
fragility as measured with ektacytometry (ie, measurement of the
shear stress a red blood cell can withstand before lysing)
• Negative Coombs test
• Family history of anemia, jaundice, splenectomy
• Differential Diagnosis
• Autoimmune hemolytic anemia
• Hemoglobin C disease
• Iron deficiency anemia
• Alcoholism
• Burns
• Treatment
• Oral folic acid supplementation
• Pneumococcal vaccination if splenectomy contemplated
• Splenectomy for symptomatic patients
• Pearl
The only condition in medicine causing a hyperchromic, microcytic
anemia.
Reference
Tse WT et al: Red blood cell membrane disorders. Br J Haematol 1999;104:2.
[PMJD: 10027705]
Chapter 5 Hematologic Diseases 115
+
Paroxysmal Nocturnal Hemoglobinuria
• Essentials of Diagnosis
• Episodic red-brown urine, especially on first morning specimen
• Variable anemia with or without leukopenia, thrombocytopenia;
reticulocytosis; positive urine hemosiderin, elevated serum LOH
• Row cytometry of red cells negative for C055 or C059, positive
sucrose hemolysis test or Ham's test
• Iron deficiency often concurrent
• Intra-abdominal venous thrombosis in some patients
• Differential Diagnosis
• Hemolytic anemias
• Myelodysplasia
• Pancytopenia due to other causes
• Treatment
• Prednisone for moderate to severe cases
• Oral iron replacement if iron-deficient
• Allogeneic bone marrow transplantation for severe cases
• Long-term anticoagulation for thrombotic events
• Pearl
One ofthefew hemolytic anemias associated with iron deficiency; most
hemolysis occurs extravascularly with conservation ofiron.
Reference
Nishimura J et aJ: ParoxysmaJ nocturnal hemoglobinuria: An acquired genetic
disease. Am J Hematol J999;62: J75. [PMID: 10539884]
+
116 Essentials of Diagnosis & Treatment
Thalassemia Major
• Essentials of Diagnosis
• Severe anemia from infancy; positive family history
• Massive splenomegaly
• Hypochromic, microcytic red cells with severe poikilocytosis,
target cells, acanthocytes, and basophilic stippling on smear
• Mentzer's index (MCY/RBC) < 13
• Greatly elevated hemoglobin F level
• Differential Diagnosis
• Other hemoglobinopathies
• Congenital nonspherocytic hemolytic anemia
• Treatment
• Regular red blood cell transfusions
• Oral folic acid supplementation
• Splenectomy for secondary hemolysis due to hypersplenism
• Deferoxamine to avoid iron overload
• Allogeneic bone marrow transplantation in selected cases
• Pearl
With low-Mev anemia in a patient of Mediterranean origin, thalassemia
is the preswnptive diagnosis until proved otherwise.
Reference
Rund D et al: New trends in the treatment of beta-thalassemia. Crit Rev Oneol
Hematol 2000;33: I05. [PMID: 10737372]
Chapter 5 Hematologic Diseases 117
Beta-Thalassemia Minor
+
• Essentials of Diagnosis
• Symptoms variable depending on degree of anemia; no specific
physical findings
• Mild and persistent anemia, hypochromia with microcytosis and
target cells; red blood cell count normal or elevated
• Similar findings in one of patient's parents
• Patient often of Mediterranean, African, or southern Chinese
ancestry
• Elevated hemoglobin A2 and hemoglobin F
• Mentzer's index (MCV/RBC) < 13
• Differential Diagnosis
• Iron deficiency anemia
• Other hemoglobinopathies, especially hemoglobin C disorders
• Sideroblastic anemia
• Alpha-thalassemia
• Anemia of chronic disease
• Treatment
• Oral folic acid supplementation
• Avoidance of medicinal iron or oxidative agents
• Red blood cell transfusions during pregnancy or stress (intercurrent
illness) if hemoglobin falls below 9 g/dL
• Pearl
The hemoglobinopathies exhibit central red cell targeting; liver disease
targeting tends to be eccentric.
Reference
Olivieri NF: The beta-thalassemias. N Engl J Med 1999;341 :99. [PMlD:
10395635]
+
118 Essentials of Diagnosis & Treatment
Alpha-Thalassemia Trait
• Essentials of Diagnosis
• Commonly comes to attention because of CBC done for other
reasons
• Increased frequency in persons of African, Mediterranean, or
southern Chinese ancestry
• Microcytosis out of proportion to anemia; occasional target cells
and acanthocytes on smear but far less so than beta; normal iron
studies
• Mentzer's index (MCY/RBC) < 13
• No increase in hemoglobin A2 or hemoglobin F
• Diagnosis of exclusion in patient with modest anemia (definitive
diagnosis depends on hemoglobin gene mapping)
• Differential Diagnosis
• Iron deficiency anemia
• Other hemoglobinopathies
• Sideroblastic anemia
• Beta-thalassemia minor
• Treatment
• Oral folic acid supplementation
• Avoidance of medicinal iron or oxidative agents
• Red blood cell transfusions during pregnancy or stress (intercurrent
illness) if hemoglobin falls below 9 g/dL
• Pearl
Microcytosis without anemia or hyperchromia is with few exceptions
alpha-thalassemia.
Reference
Bowie LJ et aJ: Alpha thalassemia and its impact on other clinical conditions.
Clin Lab Med 1997;17:97. [pMlD: 9138902]
Chapter 5 Hematologic Diseases 119
Sickle Cell Anemia
+
• Essentials of Diagnosis
• Caused by substitution of valine for glutamine in the sixth position
on the beta chain
• Recurrent episodes of fever with pain in arms, legs, or abdomen
starting in early childhood
• Splenomegaly in early childhood only; jaundice, pallor; adults
are functionally asplenic
• Anemia and elevated reticulocyte count with irreversibly sickled
cells on peripheral smear; elevated indirect bilirubin, LDH; positive
sickling test; hemoglobin Sand F on electrophoresis
• Complications include salmonella osteomyelitis, remarkably high
incidence ofencapsulated infections, and ischemic complications in
any sluggish or hypoxic part of the circulation (eg, medullary interstitium
of kidney)
• Five types of crises: pain, aplastic, megaloblastic, sequestration,
hemolytic
• Positive family history and lifelong history of hemolytic anemia
• Differential Diagnosis
• Other hemoglobinopathies
• Acute rheumatic fever
• Osteomyelitis
• Acute abdomen due to any cause
• If hematuria present, renal stone or tumor
• Treatment
• Chronic oral folic acid supplementation
• Hydration and analgesics
• Hydroxyurea for patients with frequent crises
• Partial exchange transfusions for intractable vaso-occlusive crises,
acute chest syndrome, stroke or transient ischemic attack, priapism
• Transfusion for hemolytic or aplastic crises and during third
trimester of pregnancy
• Pneumonia vaccination
• Genetic counseling
• Pearl
In regard to sickle cell anemia: anything disease can do, so may trait.
Reference
Serjeant GR: Sickle-cell disease. Lancet 1997;350:725. [PMID: 92911916]
120 Essentials of Diagnosis & Treatment
Hemoglobin SC Disease
• Essentials of Diagnosis
• Recurrent attacks of abdominal, joint, or bone pain
• Splenomegaly, retinopathy (similar to diabetes)
• Mild anemia, reticulocytosis, and few sickle cells on smear but
many targets; 50% hemoglobin C, 50% hemoglobin S on electrophoresis
• In situ thrombi of pulmonary artery and venous sinus of brain
may simulate pulmonary emboli, may cause stroke
• Differential Diagnosis
• Sickle cell anemia
• Sickle thalassemia
• Hemoglobin C disease
• Cirrhosis
• Pulmonary embolism
• Beta thalassemia
• Treatment
• No specific therapy for most patients
• Otherwise treat as for SS hemoglobin
• Pearl
Unique among hemoglobinopathies, thrombotic complications are most
severe during pregnancy.
Reference
Moll S et al: Hemoglobin SC disease. Am J Hematol 1997;54:313. [PMID:
9092687]
Chapter 5 Hematologic Diseases 121
+
Hemoglobin S-Thalassemia Disease
• Essentials of Diagnosis
• Recurrent attacks of abdominal, joint, or bone pain
• Splenomegaly
• Mild to moderate anemia with low MCV; reticulocytosis; few
sickle cells on smear with many target cells; increased hemoglobin
A2 by electrophoresis distinguishes from sickle cell disease,
hemoglobin C
• Differential Diagnosis
• Sickle cell anemia
• Hemoglobin C disease
• Hemoglobin SC disease
• Cirrhosis
• Treatment
• Chronic oral folic acid supplementation
• Acute therapy as in sickle cell anemia
• Pearl
Like other sickle hemoglobin positives, complications tend to be less
severe than in SC disease.
Reference
Clarke GM et al: Laboratory investigation of hemoglobinopathies and thalassemias:
review and update. Clin Chern 2000;46(8 Part 2): 1284. [PMID:
10926923]
122 Essentials of Diagnosis &Treatment
Sideroblastic Anemia
• Essentials of Diagnosis
• Dimorphic (ie, normal and hypochromic) red blood cell population
on smear
• Hematocrit may reach 20%
• Most often result of clonal stem cell disorder, though rarely may
be drugs, lead, or alcohol; may be a megaloblastic component
• Elevated serum iron with high percentage saturation; marrow is
diagnostic with abnormal ringed sideroblasts (iron deposits encircling
red blood cell precursor nuclei)
• Minority progress to acute leukemia
• Differential Diagnosis
• Iron deficiency anemia
• Post-transfusion state
• Anemia of chronic disease
• Thalassemia
• Treatment
• Remove offending toxin if present
• Chelation therapy for lead toxicity
• Pyridoxine 200 mg/d occasionally helpful
• Does not respond to erythropoietin (epoetin alfa)
• Pearl
In the anemic alcoholic patient who is not bleeding, sideroblastic anemia
may be the diagnosis; reticulocytosis 3 days after discontinuation
ofethanol is characteristic, at which time the serum iron falls abruptly.
Reference
Sheth S el al: Genetic disorders affecting proteins of iron metabolism: clinical
implications. Annu Rev Med 2000;51 :443. [pMID: 10774476]
Chapter 5 Hematologic Diseases 123
Vitamin 812 Deficiency
+
• Essentials of Diagnosis
• Dyspnea on exerrion, nonspecific gastrointestinal symptoms
• Constant symmetric numbness and tingling of the feet; later, poor
balance and dementia manifest
• Pallor, mild jaundice, decreased vibratory and position sense
• Pancytopenia with oval macrocytes and hypersegmented neutrophils,
increased MCV, megaloblastic bone marrow; low serum _
vitamin B12; positi ve Schilling test
• Neurologic manifestations occur without anemia in rare cases,
including dementia
• Hematologic response to pharmacologic doses of folic acid
• History oftotal gastrectomy, bowel resection, bacterial overgrowth,
fish tapeworm, Crohn's disease, or autoimmune endocrinopathies
(eg, diabetes mellitus, hypothyroiclism)
• Differential Diagnosis
• Folic acid deficiency
• Myelodysplastic syndromes
• Occasional hemolytic anemias with megaloblastic red cell precursors
ill marrow
• Infiltrative granulomatous or malignant processes causing pancytopenia
• Hypersplenism
• Paroxysmal nocturnal hemoglobinuria
• Acute leukemia
• Treatment
• Vitamin 8 12 100 ~g intramuscularly daily during first week, then
weekly for I month
• Lifelong BI2 100 ~g intramuscularly every month thereafter
• Hypokalemia may complicate early therapy
• Pearl
An arrest in reticulocytosis shortly after institution of therapy means
concealed iron deficiency until proved otherwise.
Reference
Hoffbrand AV et al: Nutritional anemias. Semin Hematol 1999;36(4 Suppl
7):13. [PMlD: 10595751]
+
-
124 Essentials of Diagnosis &Treatment
Folic Acid Deficiency
• Essentials of Diagnosis
• Nonspecific gastrointestinal symptoms, fatigue, dyspnea without
neurologic complaints in a patient with malnutrition, often related
to alcoholism
• Pallor, mild jaundice
• Pancytopenia, but counts not as low as in vitamin B'2 deficiency;
oval macrocytosis and hypersegmented neutrophils; megaloblastic
marrow; normal vitamin B,2 levels
• Red blood cell folate < 150 ng/mL diagnostic
• Differential Diagnosis
• Vitamin B'2 deficiency
• Myelodysplastic syndromes
• Infiltrative granulomatous or neoplastic bone marrow process
• Hypersplenism
• Paroxysmal nocturnal hemoglobinuria
• Acute leukemia
• Treatment
• Exclude vitamin Bt2 deficiency prior to therapy
• Oral folic acid supplementation
• Pearl
In countries such as England where vegetables may be overcooked,
folate deficiency may occur in otherwise adequately nourished persons.
Reference
Snow CF: Laboratory diagnosis of vitamin B'2 and folate deficiency: a guide
for the primary care physician. Arch Intern Med 1999;159:1289. [PMID:
103865055]
Chapter 5 Hematologic Diseases 125
Pure Red Cell Aplasia
+
• Essentials of Diagnosis
• Autoimmune disease in which IgG antibody attacks erythroid
precursors
• Lassitude, malaise; nonspecific examination except for pallor
• Severe anemia with normal red blood cell morphology; myeloid
and platelet lines unaffected; low or absent reticulocyte count
• Reduced or absent erythroid precursors in normocellular marrow
• Rare associations with systemic lupus erythematosus, chronic
lymphocytic leukemia, non-Hodgkin's lymphoma and thymoma
• Differential Diagnosis
• Aplastic anemia
• Myelodysplastic syndromes
• Drug-induced red cell aplasia
• Parvovirus B 19 infection
• Treatment
• Evaluate for underlying disease
• Immunosuppressive therapy with prednisone, cyclophosphamide,
anti thymocyte globulin
• High-dose intravenous immune globulin in selected patients
• Thymectomy in patients with thymoma may be beneficial
• Pearl
In patients who have red cell aplasia and arthritis without other features
ofsystemic lupus erythematosus, parvovirus B19 infection is an
underapprecialed diagnosis.
Reference
Erslev AJ et al: Pure red-cell aplasia: a review. Blood Rev 1996;10:20. [PMID:
8861276]
+
126 Essentials of Diagnosis & Treatment
Agranulocytosis
• Essentials of Diagnosis
• Malaise of abrupt onset, chills, fever, sore throat
• Mucosal ulceration
• History of drug ingestion common (eg, trimethoprim-sulfamethoxazole,
ganciclovir, propylthiouracil)
• Profound granulocytopenia with relative lymphocytosis
• Differential Diagnosis
• Aplastic anemia
• Myelodysplasia
• Systemic lupus erythematosus (SLE)
• Viral infection (HIV, CMV, hepatitis)
• Acute leukemia
• Felty's syndrome
• Treatment
• Stop offending drugs
• Broad-spectrum antibiotics for fever
• Trial of filgrastim (granulocyte cell-stimulating factor) for severe
neutropenia
• Allogeneic bone marrow transplant for appropriate refractory
patients
• Pearl
Sequential neutrophil counts are valueless in at-risk patients; a normal
neutrophil count today may be agranulocytosis tomorrow.
Reference
Mylonakis E et al: Resolution of drug-induced agranulocytosis. Geriatrics 2000;
55:89. [PMTD: 10711310]
Chapter 5 Hematologic Diseases 127
Aplastic Anemia
+
• Essentials of Diagnosis
• Lassitude, fatigue, malaise, other nonspecific symptoms
• Pallor, purpura, mucosal bleeding, petechiae, signs of infection
• Pancytopenia with normal cellular morphology; hypocellular bone
marrow with fatty infiltration
• Occasional history of exposure to an offending drug or radiation
• Differential Diagnosis
• Bone marrow infiltrative process (tumor, some infections, granulomatous
diseases)
• Myelofibrosis
• Acute leukemia
• Hypersplenism
• Viral infections including HlV, hepatitis
• SLE
• Treatment
• Allogeneic bone marrow transplantation for patients under age 30
• Intensive immunosuppression with antithymocyte globulin, CYclOsporine
if transplant not feasible
Oral androgens may be of benefit
• If SLE associated, plasmapheresis and corticosteroids effective
• Avoid transfusions if possible in patients who may be transplant
candidates; otherwise, red blood cells and platelet transfusions,
filgrastim (granulocyte cell-stimulating factor) or sargramostim
(granulocyte-macrophage cell-stimulating factor) as necessary
• Pearl
The risk of aplastic anemia from chloramphenicol is one in 40,000
courses; chloramphenicol is underused because of this overexaggerated
risk.
Reference
Ball SE: The modem management of severe aplastic anaemia. Bf J Haematol
2000; I 10:41. [PMlD: 10930978]
+
128 Essentials of Diagnosis & Treatment
Acute Leukemia
• Essentials of Diagnosis
• Crisp onset of fever, weakness, malaise, bleeding, bone or joint
pain, infection
• Pallor, fever, petechiae; lymphadenopathy, generally unimpressive;
splenomegaly unusual
• Leukocytosis or cytopenia of any or all three cell lines; immature,
abnormal white cells in bone marrow, often in peripheral blood
• Abnormal cells are either Iymphoblasts (ALL) or myeloblasts
(AML); Auer rods indicate the latter
• Seven types of morphology depending on cell of origin in
patients with AML
• Differential Diagnosis
• Aplastic anemia
• Idiopathic thrombocytopenia purpura
• Infectious mononucleosis
• Hodgkin's or non-Hodgkin's lymphoma
• Pertussis
• Metastatic malignancy to bone marrow
• Miliary tuberculosis
• Paroxysmal nocturnal hemoglobinuria
• Treatment
• Aggressive combination chemotherapy with specific drugs dictated
by cell type
• Conventional-dose chemotherapy curative in minority of adults
with acute leukemia; allogeneic and autologous bone marrow
transplantation considered for appropriate patients
• Pearl
Remember that pain in expansile bone marrow can simulate mechanical
back pain with bilateral leg radiation.
Reference
LOwenberg B et al: Acute myeloid leukemia. N Engl J Med 1999;341:1051.
[PMJD: 10502596]
Chapter 5 Hematologic Diseases 129
+
Chronic Myelogenous Leukemia
• Essentials of Diagnosis
• Symptoms variable; often diagnosed by examination or blood
count done for unrelated reasons
• Splenomegaly in all cases; sternal tenderness in some
• Leukocytosis, typically striking; immature white cells in peripheral
blood and bone marrow; thrombocytosis, eosinophilia, basophilia
common
• Diagnosis relies on demonstration of Philadelphia chromosome
t(9:22) by conventional cytogenetics, PCR of peripheral blood or
bone marrow, or fluorescent in situ hybridization
• Low leukocyte alkaline phosphatase level, markedly elevated
serum vitamin Bl2 due to high Bl2 binding transcobalarnins
• Results in acute leukemia in 3-5 years
• Differential Diagnosis
• Leukemoid reactions associated with infection, inflammation, or
cancer
• Other myeloproliferative disorders
• Treatment
• Tyrosine kinase inhibitor (STI57 I ; imitanib mesylate [Gleevec])
targeting specific molecular defect in CML cells is now first-line
therapy in many centers
• Combination of cytarabine (Ara-C) and interferon leads to cytogenetic
complete remissions in small minority of patients
• Allogeneic bone marrow transplantation remains useful therapy
for appropriate candidates
• Pearl
Pseudohypoglycemia and pseudohyperkalemia are in vitro artifacts resultingfrom
continuing white cell metabolism ofglucose and release of
potassium into serum after clotting. They should be considered before
inappropriate therapy is initiated.
Reference
Druker BJ et al: Efficacy and safety of aspecific inhibitor of the BCR-ABL tyrosine
kinase in chronic myeloid leukemia. N Engl J Med 2001 ;344: 103!.
[PMID: 11287972]
+
130 Essentials of Diagnosis & Treatment
Polycythemia Vera
• Essentials of Diagnosis
• Acquired myeloproliferative disorder with overproduction of all
three hematopoietic cell lines; dominated by erythrocytosis
• Pruritus (especially following a hot shower), tinnitus, blurred
vision in some
• Venous thromboses, often in uncommon sites (eg, splenic or portal
vein thromboses); plethora, splenomegaly
• Erythrocytosis; leukocytosis with eosinophilia and basophilia,
thrombocytosis common; elevated total red blood cell mass, normal
P02
• Increased serum vitamin B12 , leukocyte alkaline phosphatase levels
usually elevated; hyperuricemia
• Increased incidence of leukemia late in course; higher incidence
of peptic uleer
• Differential Diagnosis
• Hypoxemia (pulmonary or cardiac disease, high altitude)
• Carboxyhemoglobin (tobacco use)
• Certain hemoglobinopathies characterized by tight O2 binding
• Erythropoietin-secreting tumors
• Cystic renal disease
• Spurious erythrocytosis with decreased plasma volume and high
normal red cell mass (Gaisbock's syndrome)
• Other myeloproliferative disorders
• Treatment
• Phlebotomy to Hct < 45%
• Myelosuppressive therapy with radiophosphorus (32P) or alkylating
agents only for patients with high phlebotomy requirements,
intractable pruritus, or marked thrombocytosis
• Avoidance of medicinal iron; low-iron diet
Aspirin 125 mg/d if at high risk for arterial thromhosis or history
of clotting
• Deep venous thrombosis prophylaxis for any surgical procedure
or prolonged period of immobilization
• Pearl
Do not give iron to a patient with anemia from a bleeding ulcer and a
palpable spleen-the hemorrhage may be concealing this disease.
Reference
Tefferi A et al: A clinical update in polycythemia vera and essential thrombocythemia.
Am J Med 2000;109: 141. [PMID: 10967156]
Chapter 5 Hematologic Diseases 131
Essential Thrombocytosis
+
• Essentials of Diagnosis
• Sustained elevated platelet count without other cause
• Painful burning of palms and soles (erythromelalgia) promptly
and completely relieved with low-dose aspirin
• Arterial> venous thromboses
• Low likelihood of progression to fibrotic "spent" stage or acute
leukemia
• May have mild elevations in white count and hematocrit; basophilia,
eosinophilia, hypervitaminosis BJ2
• Differential Diagnosis
• Other myeloproliferative disorders (especially polycythemia vera)
• Chronic infection or autoimmune disease, visceral malignancy
(reactive thrombocytosis)
• Iron deficiency
• Treatment
• Platelet-lowering therapy for those with high risk of clotting (history
of prior clotting, older patients, established arterial vascular
disease)
• Anagrilide and hydroxyurea most commonly used agents
• Pearl
It is the qualitative (not quantitative) platelet defect that results in clotting;
reactive thrombocytosis is not a hypercoagulable state.
Reference
Tefferi A et al: A clinical update in polycythemia vera and essential thrombocythemia.
Am J Med 2000;109: 141. [PMID: 10967156]
+
132 Essentials of Diagnosis & Treatment
Myelofibrosis
• Essentials of Diagnosis
• Fatigue, abdominal discomfort, bleeding, bone pain
• Massive splenomegaly, variable hepatomegaly
• Anemia, leukocytosis or leukopenia; leukoerythroblastic peripheral
smear with marked poikilocytosis, giant platelets, left-shifted
myeloid series
• Dry tap on bone marrow aspiration
• Differential Diagnosis
• Chronic myelocytic leukemia
• Other myeloproliferative disorders
• Hemolytic anemias
• Lymphoma
• Metastatic cancer involving bone marrow
• Hairy cellieukernia
• Treatment
• Red blood cell transfusion support
• Androgenic steroids may decrease transfusion requirements
• Splenectomy for painful splenomegaly, severe thrombocytopenia,
or extraordinary red blood cell requirements
• Interferon alfa or erythropoietin (epoetin alfa)-or both-may
be of benefit in selected patients
• Pearl
With hilar adenopathy, transverse myelitis, or any mass lesion complicating
myelofibrosis, extramedullary hematopoiesis may be responsible.
Reference
Tefferi A: Myelofibrosis with myeloid metaplasia. N Engl J Med 2000;342:
J255. [pMTD: J0781623]
Chapter 5 Hematologic Diseases 133
Myelodysplastic Syndromes
+
• Essentials of Diagnosis
• Clonal hematopoietic disorder characterized by ineffective hematopoiesis
leading to peripheral cytopenias and variable presence
of blasts
• Progression as follows: refractory anemia -j refractory anemia
with ringed sideroblasts -j refractory anemia with excess blasts
(RAEB) -j RAEB in transition -j chronic myelomonocytic
leukemia
• Evolution to acute leukemia may take up to 15 years
• Morphologic dysplasia frequently seen in cells of myeloid-lineage
(eg, Pelger-Huet anomaly, hypogranular-hypolobulated neutrophils,
giant platelets)
• Previous chemotherapy (eg, procarbazine, melphalan) predisposes
• Differential Diagnosis
• Acute myeloblastic leukemia
• Anemia of chronic disease
• Alcohol-induced sideroblastic anemia
• Other causes of specific cytopenias
• Other causes of macrocytic anemias
• Treatment
• Supportive care with red cell or platelet transfusions
• Erythropoietin (epoietin alfa) and filgrastim (G-CSF) may benefit
selected patients
• Poor results with low-dose chemotherapy; azacitidine may be most
effective single agent
• Allogeneic bone marrow transplantation for appropriate patients
• Pearl
Consider myelodysplastic syndrome in older patients with hematocrits
lcss than 60% oflifctimc high and no othcr obvious causc.
Reference
Heaney ML et al: Myelodysplasia. N Engl J Med 1999;340: 1649. [PMID:
10341278]
134 Essentials of Diagnosis & Treatment
Chronic lymphocytic leukemia
+
• Essentials of Diagnosis
• Fatigue in some; most asymptomatic; often discovered incidentally
• Pallor, lymphadenopathy, splenomegaly common also
• Sustained lymphocytosis> SOOO/IlL or higher, with some counts
up to I ,OOO,OOO/IlL; morphologically mature cells in most cases
• Coombs-positive hemolytic anemia, immune thrombocytopenia,
hypogammaglobulinemia late in course
• Anemia, thrombocytopenia, bulky lymphadenopathy associated
with poorer prognosis
• Flow cytometry separates CLL from reactive lymphocytosis
• May transform into high-grade lymphoid neoplasm (Richter transformation)
• Differential Diagnosis
• Infectious mononucleosis
• Pertussis
• Lymphoma in leukemic stage
• Mantle cell lymphoma
• Hairy cell leukemia
• Treatment
• Given the chronic, frequently indolent nature of the disease, chemotherapy
is reserved for symptomatic patients or for young patients
with advanced disease
• Conventional chemotherapy unl ikely to be curative; much interest,
however. in combinations of chemotherapy and immunotherapy
• Steroids, immunoglobulin may help associated immune cytopenias
• Pearl
Smudged lymphocytic nuclei result from crushing offragile cells during
preparation ofblood smear.
Reference
Mead GM: ABC of clinical haematology. Malignant lymphomas and chronic
lymphocytic leukaemia. BMJ 1997;314: 1103. [PMlD: 9133896]
Chapter 5 Hematologic Diseases 135
Hairy Cell leukemia
+
• Essentials of Diagnosis
• Fatigue, abdominal pain, but often asymptomatic; susceptibility
to bacterial infections
• Pallor, prominent splenomegaly, rare lymphadenopathy
• Pancytopenia, "hairy cell" morphology of leukocytes in periphery
and marrow at high magnification
• "Dry tap" on bone marrow aspiration; diagnosis confirmed by
flow cytometry; tartrate-resistant acid phosphatase (TRAP) stain
also positive
• Differential Diagnosis
• Myelofibrosis
• Chronic lymphocytic leukemia
• Waldenstrom's macroglobulinemia
• Non-Hodgkin's lymphoma
• Aplastic anemia
• Acute leukemia
• Infiltration of marrow by tumor or granuloma
• Paroxysmal nocturnal hemoglobinuria
• Treatment
• Azacitidine gives durable remissions in > 80% of patients
• Splenectomy for severe cytopenias or chemotherapy-resistant
disease
• Pearl
Involved cells coexpress CDI Ic and CD22 on immunophenotyping.
Reference
Pettitt AR et al: Hairy-cell leukaemia: biology and management. BMJ 1999;
106:2. [pMTD: 10444156]
+
136 Essentials of Diagnosis &Treatment
Multiple Myeloma
• Essentials of Diagnosis
• Weakness, weight loss, recurrent infection, bone (especially
back) pain, often resulting in pathologic fractures
• Pallor, bony tenderness; spleen is not enlarged
• Anemia; accelerated sedimentation rate; elevated serum calcium,
renal insufficiency; normal alkaline phosphatase; narrowed anion
gap in most
• Nephrotic syndrome (with associated amyloidosis causing albuminuria
or by light chains in urine)
• Elevated serum globulin with monoclonal spike on protein electrophoresis
• Immature plasma cells infiltrating bone marrow; diagnostic only
when> 30% or in sheets
• Lytic bone lesions with negative bone scan
• Differential Diagnosis
• Metastatic cancer
• Lymphoma with monoclonal spike
• Hyperparathyroidism
• Waldenstrom's macroglobulinemia
• Benign monoclonal gammopathy
• Primary amyloidosis
• Treatment
• Pamidronate for patients with extensive bone disease or hypercalcemia
Autologous bone marrow transplant now standard for disease
palliation, though unlikely to be curative
• Combination chemotherapy with alkylating agents (eg, melphalan),
steroids, and vincristine used frequently pretransplant, or for
patients not able to undergo transplantation.
Radiation therapy for local hone pain or pathologic fractures
• Thalidomide effective for those with advanced or relapsed or
refractory disease
• Pearl
The counterintuitive three noes of myeloma: no fever, no increased
alkaline phosphatase, no splenomegaly.
Reference
George ED et at: Multiple myeloma: recognition and management. Am Fam
Physician 1999;59:1885. [PMlD: 10208707]
Chapter 5 Hematologic Diseases 137
+
Waldenstrom's Macroglobulinemia
• Essentials of Diagnosis
• Fatigue, symptoms ofhyperviscosity (altered mental status, bleeding,
or thrombosis)
• Variable hepatosplenomegaly and lymphadenopathy; boxcar retinal
vein engorgement
• Anemia with rouleau formation; monoclonal IgM paraprotein;
increased serum viscosity; narrowed anion gap
• Plasmacytoid infiltrate in marrow
• Absence of bone lesions
• Differential Diagnosis
• Benign monoclonal gammopathy
• Chronic lymphocytic leukemia with M spike
• Multiple myeloma
• Lymphoma
• Treatment
• Plasmapheresis for severe hyperviscosity (stupor or coma)
• Chemotherapy including chlorambucil, cyclophosphamide, fludarabine,
cladribine
• Monoclonal antibody therapy (rituximab) may be effective
• Pearl
There are rouleaux and then there are rouleaux; some can be found on
any blood smear, but they are abundant in Waldenstrom's macroglobulinemia
and myeloma.
Reference
Owen RG et al: Waldenslrom's macroglobulinaemia: laboratory diagnosis and
treatment. Hematol OncoI2000;18:41. [PMID: (VI: 10960874]
+
138 Essentials of Diagnosis &Treatment
Non-Hodgkin's Lymphoma
• Essentials of Diagnosis
• Many symptom-free and come to attention because of lymphadenopathy
• Fever, night sweats, weight loss in many
• Common in HIV infection, where isolated central nervous system
lymphoma and other extranodal involvement are typical
• Behaves as though origin is multicentric
• Variable hepatosplenomegaly; rubbery enlargement of lymph
nodes
• Lymphatic and extranodal masses on imaging; elevated LDH in
many, bone marrow positive in one-third
• Lymph node or involved extranodal tissue biopsies diagnostic;
most useful clinical classification (based on nodal architecture) is
low-, medium-, and high-grade
• Differential Diagnosis
• Hodgkin's disease
• Metastatic cancer
• Infectious mononucleosis
• Cat-scratch disease
• Pseudolymphoma caused by phenytoin
• Sarcoidosis
• Primary HIV infection
• Treatment
• Staging with CTscans of the chest, abdomen, and pelvis; gallium
or PET scan (for aggressive disease); bone marrow biopsy and
lumbar puncture in selected cases
• Treatment individualized depending on histology and prognostic
factors: age, stage, serum LDH, extranodal disease, performance
status
• With indolent disease, local radiation therapy; chemotherapy for
symptomatic, more aggressive advanced disease; monoclonal
antibody therapy useful in relapses.
• Autologous bone marrow transplantation effective in relapsed
aggressive lymphoma and perhaps for high-risk primary lymphoma.
• Pearl
A single intracranial lesion in an AIDS patient is lymphoma, multiple
lesions toxoplasmosis until proved otherwise.
Reference
DeVita VT Jr et al: The lymphomas. Semin Hematol 1999;36(4 Suppl 7):84.
[pMTD: 10595757]
Chapter 5 Hematologic Diseases 139
Hodgkin's Disease
+
• Essentials of Diagnosis
• In most cases the disorder starts in one node group and spreads in
an orderly, contiguous fashion
• Regionally enlarged, rubbery, painless lymphadenopathy (often
cervical); hepatosplenomegaly variable
• Reed-Sternberg cells (or variants) in lymph node or bone marrow
biopsy diagnostic
• Patients considered stage A if no constitutional symptoms are
present and stage B if they have fevers, night sweats, or significant
weight loss
• Younger patients have supradiaphragmatic disease with favorable
histology; older individuals tend toward more aggressive
pathology, infradiaphragmatic involvement
• Differential Diagnosis
• Non-Hodgkin's lymphoma
• Lymphadenitis secondary to infections (tuberculosis and catscratch
disease)
• Pseudolymphoma caused by phenytoin
• Lymphomatoid granulomatosis
• Sarcoidosis
• HIV disease
• SLE
• Treatment
• Staging (I-IV) with chest x-ray, CT scans ofchest, abdomen, and
pelvis, gallium or PET scan, and bone marrow biopsy; laparotomy
(if results would alter therapy) now infrequently necessary
• Radiation therapy for localized disease or short course of combination
chemotherapy with less extensive radiation
• Combination chemotherapy for disseminated disease with or
without radiation to hulky areas of disease
• Pearl
When a patient develops pain in a lymph node soon after drinking alcohol,
think Hodgkin's.
Reference
Eghbali H et al: Current treatment of Hodgkin's disease. Crit Rev Oneol Hema1012000;
35:49. [PMTD: 10863151]
+
140 Essentials of Diagnosis & Treatment
Idiopathic Thrombocytopenic Purpura
• Essentials of Diagnosis
• Mucosal bleeding, easy bruising and bleeding
• Petechiae, ecchymoses; splenomegaly rare
• Severe thrombocytopenia, prolonged bleeding time; elevated
platelet-associated IgG in 95%, though nonspecific; bone marrow
with normal to increased megakaryocytes
• May be associated with autoimmune diseases (eg, SLE), HIY
infection, lymphoproliferative disorders, or with Coombs-positive
hemolytic anemia (Evans's syndrome)
• Differential Diagnosis
• Acute leukemia
• Myelodysplastic syndrome
• TIP
• Disseminated intravascular coagulation
• Chronic lymphocytic leukemia
• Aplastic anemia
• Alcohol abuse
• Drug toxicity (eg, quinidine, digoxin)
• AIDS
• SLE
• Treatment
• Prednisone, intravenous immune globulin, or anti Rh-D immune
globulin (WinRho) in Rh-positive patients all have high rates of
success acutely
• Splenectomy if no response to initial therapy, for relapsed disease,
or for patients requiring high doses of steroids to maintain
an acceptable platelet count
• Danazol, vincristine, vinblastine, azathioprine, or cyclophosphamide
for refractory cases; plasma immunoadsorption may also be
successful in some refractory cases
• Reserve platelet transfusion for life-threatening hemorrhages;
bleeding sometimes stops even as the platelet count rises slightly
if at all
• Pearl
The order ofplatelet bleeding as the count falls: first skin, then mucous
membrane, finally viscera. Thus, absence ofcutaneous petechiae means
a low likelihood ofin tracranial hemorrhage.
Reference
George IN et al: Idiopathic thrombocytopenic purpura: diagnosis and management.
Am J Med Sci 1998;316:87. [pMID: 9704662]
Chapter 5 Hematologic Diseases 141
Von Willebrand's Disease
• Essentials of Diagnosis
• History of lifelong excessive bruising and mucosal bleeding;
excessive bleeding during previous surgery, dental extraction, or
childbirth
• Usually prolonged bleeding time, especially after aspirin, but
platelet count normal
• Variable abnormalities in factor VIII level, von Willebrand factor,
or nstocetin cofactor activity
• Prolonged partial thromboplastin time when factor VIII levels
decreased
• Differential Diagnosis
• Qualitative platelet disorders
• Waldenstrom's macroglobulinemia
• Aspirin ingestion
• Hemophilias
• Dysfibrinogenemia
• Treatment
• Avoid aspirin
• vWF and factor VllI concentrates for severe bleeding or for surgical
procedures in most cases
• Desmopressin acetate in type I disease may be sufficient to raise
vWF and factor VIII to acceptable levels
• Tranexamic acid for bleeding not responsive to other interventions
• Pearl
Remember von Willebrand's disease in patients who have a past surgical
history oferratic bleeding patterns; aspirin may have been given in
the bleeding instances, other analgesics when hemostasis was more
easily achieved.
Reference
Aledort LM: von Willebrand disease: from the bedside to therapy. Thromb
Haemost 1997;78:562. [PMTD: 9198216]
+
142 Essentials of Diagnosis & Treatment
Hemophilia A&B
• Essentials of Diagnosis
• Lifelong history of space bleeding in a male
• Slow, prolonged bleeding after minor injury or surgery; spontaneous
hemarthroses common
• Prolonged partial thromboplastin time corrected by mixing patient's
plasma with a normal specimen
• Low factor VIII coagulant activity (hemophilia A) or factor IX
coagulant activity (hemophilia B)
• Differential Diagnosis
• Von Willebrand's disease
• Disseminated intravascular coagulation
• Afibrinogenemia and dysfibrinogenemia
• Heparin administration
• Acquired factor deficiencies or inhibitors (eg, paraproteins with
anti-VIII or anti-IX activity)
• Treatment
• Avoidance of aspirin
• Factor replacement for any bleeding with factor VIII concentrates
(hemophilia A) or factor IX complex (hemophilia B) or during
invasive procedures
• Increased factor dosing, steroids, or immunosuppressants if factor
inhibitor develops
• Desmopressin acetate before surgical procedures for hemophilia
A may benefit selected patients
• Pearl
Christmas disease (factor IX deficiency) is the index patient's name, not
the holiday.
Reference
Mannucci PM et al: The hemophilias: progress and problems. Semin Hematol
1999;36(4SuppI7):104. [PMlD: 10595759]
G
Rheunlatologic ..
Autoimnlune Disorders
Degenerative Joint Disease (Osteoarthritis)
• Essentials of Diagnosis
• Progressive degeneration of articular cartilage and hypertrophy
of bone at the articular margin
• Affects almost all joints, especially weight-bearing and frequently
used joints; hips, knees, shoulders, and first carpometacarpal joint
most common
• May be primary (idiopathic) or secondary to trauma, metabolic
abnormality, or other articular disease
• Primary degenerative joint disease most commonly affects the
terminal interphalangeal joints (Heberden' s nodes), hips, and first
carpometacarpal joints
• Morning stiffness brief; articular inAammation minimal
• Radiographs reveal narrowing of the joint spaces, osteophytes,
increased density of subchondral bone, subchondral cysts
• Differential Diagnosis
• Rheumatoid arthritis
• Seronegative spondyloarthropathies
• Crystal-induced arthritides
• Hyperparathyroidism
• Multiple myeloma
• Hemochromatosis
• Treatment
• Weight reduction
• Exercises to strengthen muscles around affected joints
• Aspirin, other NSAIDs (eg, ibuprofen, 600 mg three times daily)
or COX-2 inhibitors
• Glucosamine and chondroitin sulfate appear to be effective
• Intra-articular corticosteroid injection (eg, triamcinolone,
10-40 mg) in selected cases
• Surgery for severely affected joints, especially hip
• Pearl
Thefirst metatarsophalangeal joint harbors the most subclinical degenerative
disease and thus is the most common nidus for gout.
Reference
Manek NJ et al: Osteoarthritis: current concepts in diagnosis and management.
Am Fam Physician 2000;61:1795. [PMID: 10750883]
143
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
+
144 Essentials of Diagnosis &Treatment
Gout
• Essentials of Diagnosis
• Spectrum of disease, including recurrent arthritic attacks, tophi,
interstitial nephropathy, and uric acid nephrolithiasis
• First attack typically nocturnal and usually monarticular; may be
polyarticular with repeated attacks
• Affects first metatarsophalangeal joint (podagra), mid foot, ankle,
knees, wrist, elbow-hips and shoulders spared
• Hyperuricemia may be primary (caused by overproduction [10%]
or underexcretion [90%] of uric acid) or secondary to diuretic use,
cytotoxic drugs (especially cyclosporine), myeloproliferative disorders,
multiple myeloma, hemoglobinopathies, chronic renal
disease, hypothyroidism
• After long periods of untreated hyperuricemia, tophi (monosodium
urate deposits with an associated foreign body reaction) develop in
subcutaneous tissues, bone, cartilage, joints, and other tissues
• Identification of weakly negatively birefringent, needle-like sodium
urate crystals in joint fluid or tophi is diagnostic
• Differential Diagnosis
• Cellulitis
• Septic arthritis
• Pseudogout
• Rheumatoid arthritis
• Calcium oxalate deposition disease
• Chronic lead intoxication (saturnine gout)
• Treatment
• Treat the acute arthritis first and the hyperuricemia later, if at all
• For acute attacks: dramatic therapeutic response to NSAIDs (eg,
indomethacin, 50 mg three times daily), colchicine, intra-articular
or systemic corticosteroids
• For chronic prophylaxis in patients with frequent acute attacks,
tophaceous deposits, or renal damage: allopurinol and probenecid
(uricosuric agent) with concomitant colchicine
• Avoid thiazides and loop diuretics
• Pearl
Long-standing"rheumatoid arthritis" sparing the shoulders and hips
is most likely gout.
Reference
Pascual E: Gout update: from lab to the clinic and back. Curr Opin Rheumatol
2000;12:213. [PMlD: 10803751]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 145
Chondrocalcinosis &Pseudogout
(Calcium Pyrophosphate Dihydrate Deposition Disease)
• Essentials of Diagnosis
• Chondrocalcinosis a central feature
• Subacute, recurrent, and (rarely) chronic arthritis, usually involving
large joints (especially knees, shoulders, and wrists) and almost
always accompanied by chondrocalcinosis of the affected joints
• May be hereditary, idiopathic, or associated with metabolic disorders,
including hemochromatosis, hypoparathyroidism, osteoarthritis,
ochronosis, diabetes mellitus, hypothyroidism, Wilson's
disease, and gout
• Identification of calcium pyrophosphate rhomboidal crystals
(strong positive birefringence) in the joint fluid is diagnostic
• Radiographs may reveal chondrocalcinosis or signs of degenerative
joint disease at the following sites: knee (medial meniscus),
fibrocartilaginous portion of the symphysis pubica, and articular
disk of the wrist
• Differential Diagnosis
• Gout
• Calcium phosphate disease (hydroxyapatite arthropathy)
• Calcium oxalate deposition disease
• Degenerative joint disease
• Rheumatoid arthritis
• Treatment
• Treat underlying disease if present
• Aspirin, other NSAIDs (eg, indomethacin, 50 mg three times daily)
• Intra-articular injection of corticosteroids (eg, triamcinolone,
10-40 mg)
• Colchicine, 0.6 mg twice daily, occasionally useful for prophylaxis
• Pearl
Pseudogout and gout may coexist in the same joint at the same time.
Reference
Pam AG: What is new about crystals other than monosodium urate~ Curr Opin
RheumaloI2000;12:228. [PMTD: 10803754]
+
146 Essentials of Diagnosis &Treatment
Rheumatoid Arthritis
• Essentials of Diagnosis
• Symmetric polyarthritis of peripheral joints with pain, tenderness,
and swelling; morning stiffness common
• Chronic, persistent synovitis with formation of pannus that erodes
cartilage, bone, ligaments, and tendons
• Joint deformities may develop; ulnar deviation common
• IgM rheumatoid factor present in up to 85%; 20% of seropositive
patients have subcutaneous nodules
• Extra-articular manifestations include vasculitis, pleural effusion
(low in glucose), scleritis, sicca symptoms, Felty's syndrome;
usually in strongly seropositive patients
• Radiographic findings include juxta-articular and sometimes generalized
osteopenia, narrowing of the joint spaces, and bony erosions,
particularly of the MCPs and ulnar styloid
• Differential Diagnosis
• SLE
• Degenerative joint disease; polymyalgia rheumatica
• Gout or pseudogout
• Lyme disease
• Sjogren's syndrome
• Inflammatory osteoarthritis
• Treatment
• Pharmacologic doses of aspirin, other NSAIDs
• Corticosteroid-sparing agents such as CQX-2 inhibitors are as
effective as other NSAIDs (eg, ibuprofen, 800 mg three times
daily) with less gastrointestinal toxicity
Disease-modifying drugs, including methotrexate, sulfasalazine,
hydroxychloroquine, azathioprine, and leflunomide (alone or in
combination) in patients with moderate disease activity or poor
prognostic features
• Refractory disease and the presence of poor prognostic features
may be treated with anti-TNF therapy (infliximab or etanercept)
• Hydroxychloroquine and minocycline have modest efficacy for
mild disease
• Surgery for severely affected joints
• Pearl
Afiare ofa single joint in a patient with established rheumatoid arthritis
means infection until excluded.
Reference
Fries JF: Cun-ent treaunent paradigms in rheumatoid arthritis. Rheumatology
2000;39(Suppl 1):30. [PMID: 11001377]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 147
Adult Still's Disease
• Essentials of Diagnosis
• Occurs in adults usually under 35; some cases into the fifties
• Fevers> 39°C may antedate arthritis by months; occasional
cases entirely nonarticular
• Polyarthritis or oligoarthritis usually affects the proximal interphalangeal
and metacarpophalangeal joints, wrists, knees, hips,
and shoulders
• Characteristic evanescent, salmon-colored maculopapular rash
involving the trunk and extremities during fever spikes; may be
elicited by mechanical irritation
• Additional findings commonly seen include hepatosplenomegaly,
lymphadenopathy, pleuropericarditis, leukocytosis, thrombocytosis,
anemia, and elevations in the erythrocyte sedimentation rate
and the C-reactive protein level
• A positive ANA > 1 : 100 or rheumatoid factor> I :80 excludes
the diagnosis
• Differential Diagnosis
• Leukemia or lymphoma
• Arthritis associated with inflammatory bowel disease or psoriasis
• Chronic infection (eg, culture-negative endocarditis)
• Systemic vasculitis
• SLE
• Lyme disease
• Granulomatous diseases (eg, sarcoidosis, Crohn's disease)
• Treatment
• Unless contraindicated, aspirin (lg four times daily) often dramatically
lyses fever
• NSAlDs (eg, ibuprofen, 800 mg three times daily)
• Corticosteroids, hydroxychloroquine, methotrexate, azathioprine,
and other immunosuppressive agents are used as second-line
agents
• Pearl
Gne ofthree diseases in all ofmedicine with biquotidianfever spikes.
Reference
Sobieska Met al: Still's disease in children and adults: a distinct panem of acutephase
proteins. Clin RheumatoI1998;17:258. [PMID: 9694067]
+
148 Essentials of Diagnosis & Treatment
Systemic Lupus Erythematosus
• Essentials of Diagnosis
• Predominantly in young women
• Multisystem inflammatory autoimmune disorder with periods of
exacerbation and remission
• Four or more of the following 11 criteria must be present: malar
("butterfly") rash, discoid rash, photosensitivity, oral ulcers, arthritis,
serositis, renal disease, neurologic disease, hematologic
disorders, positive antinuclear antibody (ANA), and immunologic
abnormalities (eg, antibody to native double stranded DNA
or to Sm, or false-positive serologic test for syphilis)
• Also associated with fever, myositis, alopecia, myocarditis, pericarditis,
vasculitis, lymphadenopathy, conjunctivitis, antiphospholipid
antibodies with hypercoagulability and miscarriages,
thrombocytopenia, glomerulonephritis (focal, membranoproliferative,
or membranous), sicca complex
• Syndrome may be drug-induced (eg, procainamide, hydralazine),
in which case brain and kidney usually spared
• Differential Diagnosis
• Rheumatoid arthritis
• Vasculitis
• Sjogren's syndrome
• Systemic sclerosis
• Endocarditis
• Lymphoma
• Glomerulonephritis due to other cause
• Treatment
• Mild disease (ie, arthralgias with dermatologic findings) often
responds to hydroxychloroquine and COX-2 inhibitors or NSAIDs
• Moderate disease activity (ie, refractory to antimalarials): corticosteroids
and azathioprine, methotrexate, or mycophenolate mofetil
• Corticosteroids and cyclophosphamide for lupus cerebritis and
lupus nephritis
• Withdraw offending agent if drug-induced lupus suspected
• Avoid sun exposure
• Pearl
The classic malar rash ofSLE ~pares the nasolabial folds.
Reference
Strand V: New therapies for systemic lupus erythematosus. Rheum Dis Clin
North Am 2000;26:389. [PMID: 10768219]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 149
Systemic Sclerosis (Scleroderma)
• Essentials of Diagnosis
• Diffuse systemic sclerosis in 20% of patients with generalized
fibrotic changes of the skin and internal organ systems
• Raynaud's phenomenon typical; may be associated with intestinal
hypomotility, pulmonary fibrosis, myocarditis, pericarditis,
hypertension and renal failure, acral ulceration
• Limited disease (80% of patients) or CREST syndrome (calcinosis
cutis, Raynaud's phenomenon, esophageal hypomotility,
sclerodactyly, and telangiectasia): skin tightening limited to the
distal extremities and feet, with lower risk of renal disease, later
onset of pulmonary hypertension and biliary cirrhosis, and an
overall better prognosis
• ANA frequently useful in systemic sclerosis; anticentromere antibody
positive in 1% of patients with diffuse scleroderma and 50%
of those with CREST syndrome; antitopoisomerase I (Scl-70) in
one-third of patients with diffuse systemic sclerosis and 20% of
those with CREST syndrome, and a poor prognostic factor
• Differential Diagnosis
• Eosinophilic fasciitis
Overlap syndromes with scleroderma
Graft-versus-host disease
Amyloidosis
Morphea
• Raynaud's disease
• Cryoglobulinemia
• Treatment
• Angiotensin-converting enzyme blockers to treat hypertensive
crisis occasionally seen in patients with systemic sclerosis
• Corticosteroids not helpful; penicillamine may be
• Warm clothing, smoking cessation, and extended-release calcium
channel blockers for Raynaud's phenomenon; intravenous iloprost
may be helpful for digital ulcers
• H2 receptor antagonists or omeprazole for esophageal reflux
• Pearl
Malabsorption in systemic sclerosis is due not to intestinal fibrosis but
to bacterial overgrowth from hypomotility.
Reference
Clements PJ: Systemic sclerosis (scleroderma) and related disorders: clinical
aspects. Baillieres Best Pfact Res Clin Rheumatol 2000;14:1. IPM1D:
10882211]
+
150 Essentials of Diagnosis & Treatment
Overlap Syndromes (Mixed Connective Tissue
Disease &Undifferentiated Connective
Tissue Syndrome)
• Essentials of Diagnosis
• Clinical features of more than one disease (SLE, systemic sclerosis,
polymyositis, and rheumatoid arthritis)
• Sicca complex (xerostomia, xerophthalmia, dry cough) and myositis
in virtually all patients
• Presence of a specific antibody to ribonuclear protein
• Suggested clinical criteria include three of the following: edema
of the hands, synovitis, myositis, Raynaud's phenomenon, and
acrosclerosis
• Associated with pulmonary fibrosis, pericarditis, myocarditis,
esophageal hypomotility, glomerulonephritis
• May evolve to one predominant phenotype over time
• Differential Diagnosis
• SLE
• Systemic sclerosis
• Polymyositis
• Sjogren's syndrome
• Rheumatoid arthritis
• Eosinophilic fasciitis
• Graft-versus-host disease
• Treatment
• NSAIDs (eg, ibuprofen, 800 mg three times daily) and CQX-2
inhibitors
• Corticosteroids often first-line agent; response good at modest
doses
• Symptomatic relief of dryness with artificial tears, chewing gum,
sialagogues, frequent sips of water
• Warm clothing, smoking cessation, and extended-relief calcium
channel blockers for Raynaud's phenomenon
• Pearl
Sicca syndrome is a cause of"refractory" angina; a drop ofwater with
nitroglycerin makes it stable angina.
Reference
Kasukawa R: Mixed connective tissue disease. Intern Med 1999;38:386. [PMID:
10397074]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 151
Polymyositis-Dermatomyositis
• Essentials of Diagnosis
• Bilateral proximal muscle weakness
• Periorbital edema and a purplish (heliotrope) rash over the upper
eyelids in many
• Violaceous, occasionally scaly papules overlying the dorsal surface
of the interphalangeal joints of the hands (Gottron' s papules)
• Serum CK elevated; ANA only uncommonly positive save in
overlap syndromes; anti-Jo-l antibodies in the subset of patients
who have associated interstitial lung disease; anti-Mi-2 is more
specific for dermatomyositis but is insensitive
• Muscle biopsy and characteristic electromyographic pattern are
diagnostic
• May be associated with rheumatoid arthritis, SLE, scleroderma,
mixed connective tissue disease; increased incidence of malignancy,
especially in older patients
• Differential Diagnosis
• Endocrine myopathies (eg, hyperthyroidism)
• Polymyalgia rheumatica
• Myasthenia gravis; Eaton-Lambert syndrome
• Muscular dystrophy
• Rhabdomyolysis
• Parasitic myositis
• Drug-induced myopathies (eg, corticosteroids, alcohol, colchicine,
statins, zidovudine, hydroxychloroquine, one batch of
L-tryptophan)
• Adult glycogen storage disease
• Mitochondrial myopathy
• Treatment
• Corticosteroids
• Methotrexate or azathioprine spares steroids
• Intravenous immune globulin for some cases of dermatomyositis
• Search for malignancy unwarranted unless historical or examination
findings indicate it
• Pearl
Biopsy at the site ofa previous EMG will show inflammation; pick the
same muscle on the other side.
Reference
Callen JP: Dermatomyositis. Lancet 2000;355:53. [PMID: 10615903]
+
152 Essentials of Diagnosis & Treatment
Sjogren's Syndrome
• Essentials of Diagnosis
• Destruction of exocrine glands, leading to mucosal and conjunctival
dryness
• Dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca),
decreased tear production, parotid enlargement, severe dental
caries, loss of taste and smell
• Occasionally associated with glomerulonephritis, renal tubular
acidosis, biliary cirrhosis, pancreatitis, neuropsychiatric dysfunction,
polyneuropathy, interstitial pneumonitis, thyroiditis, cardiac
conduction defects
• Over 50% have cytoplasmic antibodies, anti-Ro (SS-A), and antiLa
(SS-B)
• Decreased lacrimation measured by Schirmer's filter paper test;
biopsy of minor salivary glands of lower lip confirms diagnosis
• May also be observed in patients with rheumatoid arthritis, SLE,
systemic sclerosis, polymyositis, polyarteritis, fibrosis; increased
incidence of lymphoma and Waldenstrom's macroglobulinemia,
especially in isolated sicca syndrome
• Differential Diagnosis
• Sicca complex associated with other autoimmune diseases such
as sarcoidosis, rheumatoid arthritis, SLE, and systemic sclerosis
as noted
• Anticholinergic medications
• Chronic irritation from smoking
• Treatment
• Symptomatic relief of dryness with artificial tears, chewing gum,
sialagogues
• Cholinergic drugs such as pilocarpine
• Meticulous care of teeth and avoidance of sugar-containing
candies
• Corticosteroids or azathioprine; cyclophosphamide for peripheral
neuropathy, interstitial pneumonitis, glomerulonephritis, and vasculitis
• Pearl
Consider parotid tumors before making the diagnosis ofSjogren 's syndrome.
Reference
Fox R1 et at: Current issues in the diagnosis and treatment of Sjogren's syndrome.
Curr Opin Rheumatol 1999;11 :364. [PMID: 10503656]
Chapter 6 Rheumatologic & Autoimmune Disorders 153
Polyarteritis Nodosa
• Essentials of Diagnosis
• Fever, hypertension, abdominal pain, arthralgias, myalgias
• Cotton-wool spots and microaneurysms in fundus; pericarditis,
myocarditis, palpable purpura, mononeuritis multiplex, livedo
reticularis
• Acceleration of sedimentation rate in most; serologic evidence of
hepatitis B or hepatitis C in 30-50%
• ANCA positive in most
• Diagnosis confirmed by biopsy or visceral angiography
• Renal or pulmonary involvement in variant microscopic polyarteritis
• Differential Diagnosis
• Wegener's granulomatosis
• Churg-Strauss vasculitis
• Hypersensitivity vasculitis
• Subacute endocarditis
• Essential mixed cryoglobulinemia
• Cholesterol atheroembolic disease
• Treatment
• Corticosteroids with cyclophosphamide for systemic vasculitis;
azathioprine is used as a maintenance immunosuppressant
• Pearl
Treat polyarteritis nodosa with immunosuppressives at your own risk
ifendocarditis has not been definitively excluded.
Reference
Savage C et al: ABC of arterial and vascular disease: vasculitis. BMJ 2000;
320: 1325. [PMID: 10807632]
+
154 Essentials of Diagnosis &Treatment
Polymyalgia Rheumatica &Giant Cell Arteritis
• Essentials of Diagnosis
• Patients usually over age 50
• Polymyalgia rheumatica characterized by pain and stiffness, not
weakness, of the shoulder and pelvic girdle lasting I month or
more without evidence of infection or malignancy
• Associated with fever, little if any joint swelling, sedimentation
rate> 40mm/h, and rapid response to prednisone 15 mg/d
• Giant cell (temporal) arteritis frequently coexists with polymyalgia
rheumatica; headache, transient or permanent blindness, jaw
claudication, or temporal artery tenderness; lingual Raynaud's
phenomenon, scalp necrosis
• Diagnosis confirmation by 5 cm temporal artery biopsy remains
reliable for 1-2 weeks after starting steroids
• Differential Diagnosis
• Multiple myeloma
• Chronic infection, eg, endocarditis, visceral abscess
• Neoplasm
• Rheumatoid arthritis
• Depression
• Myxedema
• Carotid plaque with embolic amaurosis fugax
• Carotid Takayasu's arteritis
• Treatment
• Prednisone 10-20 mg/d for polymya1gia rheumatica
• Prednisone 60 mg/d immediately on suspicion of temporal
arteritis; treat for at least 4 months depending on response of
symptoms-not sedimentation rate
• Methotrexate or azathioprine spares steroids in some patients
with side effects on high doses
• Pearl
Instntct patients with polymyalgia rheumatica to keep 60 mg ofprednisone
with them at all times and to take it and come in ifthere are any
visual symptoms.
Reference
Epperly TD et al: Polymyalgia rheumatica and temporal arthritis. Am Fam
Physician 2000;62:789. [PMID: 10969858]
Chapter 6 Rheumatologic & Autoimmune Disorders 155
Churg-Strauss Vasculitis
(Allergic Granulomatosis &Angiitis)
• Essentials of Diagnosis
• Granulomatous vasculitis of small- and medium-sized arteries
• Four of the following have a sensitivity of 85% and specificity of
100% for diagnosis: asthma; allergic rhinitis; transient pulmonary
infiltrates; palpable purpura or extravascular eosinophils; mononeuritis
multiplex; and eosinophilia
• Differential Diagnosis
• Wegener's granulomatosis
• Eosinophilic pneumonia
• Polyarteritis nodosa (often overlaps)
• Hypersensitivity vasculitis
• Treatment
• Corticosteroids
• Cyclophosphamide in addition probably has better outcome
• Pearl
Leukotriene inhibitors such as monrelukast, given for asthma, have
been implicated as causing some cases of Churg-Strauss syndrome.
Reference
Eustace JA etal: Disease oflhe month. The Churg Strauss Syndrome. J Am Soc
NephroI1999;10:2041l. [PMID: 10477159]
+
156 Essentials of Diagnosis &Treatment
Hypersensitivity Vasculitis
• Essentials of Diagnosis
• Leukocytoclastic vasculitis of small blood vessels
• Palpable purpura of lower extremities the predominant feature
• Secondary to numerous drugs, neoplasms, connective tissue disorders,
congenital complement deficiency, serum sickness, viral
or bacterial infection
• On occasion associated with fever, arthralgias, abdominal pain
with or without gastrointestinal bleeding, pulmonary infiltrates,
kidney involvement with hematuria
• Differential Diagnosis
• Polyarteritis nodosa
• Henoch-Schonlein purpura
• Essential mixed cryoglobulinemia
• Meningococcemia
• Gonococcemia
• Treatment
• Treat underlying disease ifpresent
• Discontinue offending drug
• Corticosteroids in severe cases
• Pearl
The palpable purpura of hypersensitivity vasculitis is dependent and
thus may be prominent on the backs ofbedfast patients.
Reference
Savage CO et al: ABC of arterial and vascular disease: vasculitis. BMJ 2000;
320: 1325. [PMTD: 10807632]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 157
Wegener's Granulomatosis
• Essentials of Diagnosis
• Vasculitis associated with glomerulonephritis and necrotizing
granulomas of upper and lower respiratory tracts
• Slight male predominance with peak incidence in fourth and fifth
decades
• Ninety percent present with upper or lower respiratory tract symptoms,
including perforation of nasal septum, chronic sinusitis, otitis
media, mastoiditis, cough, dyspnea, hemoptysis
• Proptosis, scleritis, arthritis, purpura, or neuropathy (mononeuritis
multiplex) may also be present
• cANCA in 90%; sinus, lung, or renal biopsy makes the diagnosis,
though the latter is seldom specific, showing focal glomerulonephritis;
eosinophilia not a feature
• Chest film may reveal large nodular densities; urinalysis may
show hematuria, red cell casts; CT scans of sinuses often reveal
bony erosion
• Increased risk of bladder cancer and lymphoma
• Differential Diagnosis
• Polyarteritis nodosa
• Churg-Strauss vasculitis
• Goodpasture's syndrome
• Takayasu's arteritis
• Microscopic polyarteritis
• Lymphomatoid granulomatosis
• Lymphoproliferative disorders (especially angiocentric T cell
lymphoma)
• Treatment
• Corticosteroids
• Primarily oral cyclophosphamide or methotrexate in addition
• Trimethoprim-sulfamethoxazole effective in mild disease; given
to all patients not allergic to sulfonamides
• Pearl
In 10% of renal biopsies, pathoglwmonic granulomatous vasculitis is
seen in renal arterioles.
Reference
Esper GJ et al: Update on the treatment of Wegener's granulomatosis. Bull the
Rheumal Dis 1999;48: I. [pMTD: 10721552]
+
158 Essentials of Diagnosis & Treatment
Cryoglobulinemia
• Essentials of Diagnosis
• Refers to any globulin precipitable at lower than body temperature
• Any elevation of globulin may be associated
• Monoclonal gammopathies, reactive hypergammaglobulinemia,
cryoprecipitable immune complexes are the main causes; first
two have acral cold symptoms because of higher titers of cryoproteins
• Symptoms and signs depend upon type
• Low erythrocyte sedimentation rate; correctable by doing 37°C
ESR
• Differential Diagnosis
• Multiple myeloma, WaJdenstrom's macroglobulinemia
• Chronic inflammatory diseases such as endocarditis, sarcoidosis,
rheumatoid arthritis
• Essential mixed cryoglobulinemia: palpable purpura and glomerulonephritis
in patients serologicaJly positive for hepatitis C
• Treatment
• Entirely dependent on cause
• Pearl
In a patient with back pain whose blood "clots" per the laboratory
despite heparinization of the specimen, the diagnosis is myeloma with
a cryoprecipitable M-spike.
Reference
Lamprecht P et al: Cryoglobulinemic vasculitis. Arthritis Rheum 1999;42:2507.
[PMJD: 10615995]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 159
Takayasu's Arteritis ("Pulseless Disease")
• Essentials of Diagnosis
• Large-vessel vasculitis involving the aortic arch and its major
branches
• A disease of Asian women under 40
• Associated with myalgias, arthralgias, headaches, angina, claudication,
erythema nodosum-like lesions; hypertension, bruits,
absent pulses, cerebrovascular insufficiency, aortic insufficiency
• Angiography reveals narrowing, stenosis, and aneurysms of the
aortic arch and its major branches
• Bruits may be heard over the subclavian arteries or aorta in up to
40% of patients; additionally, there may be a > 10 mm Hg difference
in systolic blood pressure in the two arms
• Rich collateral flow visible in the shoulder, chest, and neck areas
• Differential Diagnosis
• Giant cell arteritis
• Syphilitic aortitis
• Severe atherosclerosis
• Treatment
• Corticosteroids
• Cyclophosphamide or methotrexate added for severe disease
• Surgical bypass or reconstruction of affected vessels
• Pearl
Clinically ana pathologically identical to giant cell arteritis except in
the strikingly disparate epidemiology.
Reference
Numano F et al: Takayasu arteritis-beyond pulselessness. Intern Med 1999;
38:226. [pMlD: 10337931]
+
160 Essentials of Diagnosis &Treatment
Thromboangiitis Obliterans (Buerger's Disease)
• Essentials of Diagnosis
• Inflammatory disease involving small- and medium-sized arteries
and veins of the distal upper and lower extremities
• Occurs primarily in young Jewish men who are heavy cigarette
smokers
• Associated with migratory superficial segmental thrombophlebitis
of superficial veins, absent peripheral pulses, claudication, numbness,
paresthesias, Raynaud's phenomenon, ulceration and gangrene
of fingertips and toes
• Angiography reveals multiple occluded segments in the small- and
medium-sized arteries of the arms and legs
• Differential Diagnosis
• Atherosclerosis
• Raynaud's disease
• Livedo reticularis due to other cause
• Antiphospholipid antibody syndrome
• Cholesterol atheroembolic disease
• Treatment
• Smoking cessation is essential
• Warm clothing, nifedipine for Raynaud's phenomenon
• Surgical sympathectomy of some value
• Amputation required in some
• Pearl
The addiction to nicotine is fierce; patients continue to smoke even with
limb prostheses.
Reference
Olin JW: Thromboangiitis obliterans (Buerger's disease). N Engl J Med 2000;
343:864. [PMID: 10995867]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 161
Beh~et's Syndrome
• Essentials of Diagnosis
• Usually occurs in young adults from Mediterranean countries or
Japan; incidence decreases if patient's descendants emigrate elsewhere
• Most common: recurrent oral aphthous ulcerations (99%), genital
ulcers (80%), ocular lesions in half (uveitis, hypopyon, iritis, keratitis,
optic neuritis), and skin lesions (erythema nodosum, superficial
thrombophlebitis, cutaneous hypersensitivity, folliculitis)
• Less common: gastrointestinal erosions, epididymitis, glomerulonephritis,
cranial nerve palsies, aseptic meningitis, and focal
neurologic lesions
• Pathergy test-a papule or a pustule forms 24-48 hours after
simple trauma such as a needle prick.
• Diagnosis is clinical
• HLA-B5 histocompatibility antigen often present
• Differential Diagnosis
• HLA-B27 spondyloarthropathies
• Oral aphthous ulcers
• Herpes simplex infection
• Erythema multiforme
• SLE
• HIV infection
• Infective endocarditis
• Treatment
• Local mydriatics in all patients with eye findings to prevent synechiae
from forming
• Corticosteroids
• Colchicine (for erythema nodosum and arthralgia)
• Azathioprine, cyclosporine in some
• Pearl
Stroke in a young native Japanese woman is Beh(:et's syndrome unless
proved othelwise.
Reference
Sakane T et al: BehGet's disease. N Engl J Med 1999;341:1284. [PMID:
10528040]
+
162 Essentials of Diagnosis & Treatment
Ankylosing Spondylitis
• Essentials of Diagnosis
• Gradual onset of backache in adults under age 40 with progressive
limitation of back motion and chest expansion
• Diminished anterior flexion of lumbar spine, loss of lumbar lordosis,
inflammation at tendon insertions
• Peripheral arteritis and anterior uveitis in many
• Aortic insufficiency with cardiac conduction defects in some
• Cauda equina syndrome, apical pulmonary fibrosis are late complications
• HLA-B27 histocompatibility antigen present in over 90% of
patients; rheumatoid factor absent
• Radiographic evidence of sacroiliac joint sclerosis; demineralization
and squaring of the vertebral bodies with calcification of
the anterior and lateral spinal ligaments (bamboo spine)
• Differential Diagnosis
• Rheumatoid arthritis
• Osteoporosis
• Reactive arthritis
• Arthritis associated with inflammatory bowel disease
Psori ati c arthri ti s
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome
• Treatment
• Physical therapy to maintain posture and mobility
• NSAIDs (eg, indomethacin 50 mg three times daily) often marginallyeffective
• Sulfasalazine reported effective in some patients
• Intra-articular corticosteroids for synovitis; ophthalmic corticosteroids
for uvei ti s
• Surgery for severely affected joints; anti-TNF agents may be
effective but are toxic
• Pearl
In a patient with burned-out ankylosing spondylitis and symptomatic
"benign prostatic hyperplasia," test the cauda equina distribution
neurologically before undertaking prostatectomy.
Reference
Koehler L et al: Managing seronegative spondarthritides. Rheumatology 2000;
39:360. [PMlD: 10817767]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 163
Psoriatic Arthritis
• Essentials of Diagnosis
• Classically a destructive arthritis of distal interphalangeal joints;
many patients also have peripheral arthritis involving shoulders,
elbows, wrists, knees, and ankles, often asymmetrically
• Sacroiliitis in B27-positive patients
• Occurs in 15-20% of patients with psoriasis
• Psoriatic arthritis associated with nail pitting, onycholysis,
sausage digits, arthritis mutilans (severe deforming arthritis)
• Rheumatoid factor negative; serum uric acid may be elevated
• Radiographs may reveal irregular destruction of joint spaces and
bone, pencil-in-cup deformity of the phalanges, sacroiliitis
• Differential Diagnosis
• Rheumatoid arthritis
• Ankylosing spondylitis
• Arthritis associated with inflammatory bowel disease
• Reactive arthritis
• Juvenile spondyloarthropathy
• Treatment
• NSAIDs (eg, ibuprofen, 800 mg three times daily) or COX-2
inhibitors
• Intra-articular corticosteroid injection; sterilize skin carefully as
psoriatic lesions are colonized with staphylococci and streptococci
• Gold salts, methotrexate
• Sulfasalazine reportedly effective in patients with symmetric polyarthritis
• Treatment of psoriasis helpful in many but not in sacroiliitis
• Pearl
In an arthritis ofuncertain cause, examination ofthe interglutealfolds
can give the diagnosis.
Reference
Gladman DD: Psoriatic arthritis. Rheum Dis Clin North Am 1998;24:829.
[PMTD: 9891713]
+
164 Essentials of Diagnosis & Treatment
Reactive Arthritis
• Essentials of Diagnosis
• Predominantly found in young men
• Triad of urethritis, conjunctivitis (or uveitis), and arthritis which
may occur within a month of another sign or symptom; conjunctivitis
may be subtle and evanescent
• Follows dysenteric infection (with shigella, salmonella, yersinia,
campylobacter) or sexually transmitted infection (with chlamydia)
• Asymmetric, oligoarticular arthritis typically involving the knees
and ankles
• Associated with fever, mucocutaneous lesions, stomatitis, aortic
regurgitation, optic neuritis, circinate balanitis, prostatitis, keratoderma
blennorrhagicum, pericarditis
• HLA-B27 histocompatibility antigen in most
• Differential Diagnosis
• Gonococcal arthritis
• Rheumatoid arthritis
• Ankylosing spondylitis
• Psoriatic arthritis
• Arthritis associated with inflammatory bowel disease
• Juvenile spondyloarthropathy
• Treatment
• NSAIDs (eg, indomethacin, 50 mg three times daily); often ineffective
• Tetracycline for associated Chlamydia trachomatis infection;
obtain VDRL, consider HlV testing
• Azathioprine, methotrexate in severe cases
• Sulfasalazine may help in some patients
Intra-articular corticosteroids for arthritis, ophthalmic corticosteroids
for uveitis
• Pearl
Synovial fluid occasionally shows characteristic cells: large mononuclear
cell with ingested polymorphonuclear leukocytes which may have
inclusion bodies.
Reference
Barth WF et al: Reactive arthritis (Reiter's syndrome). Am Fam Physician
1999;60:499. [PMlD: 10465225]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 165
Arthritis Associated with Inflammatory
Bowel Disease
• Essentials of Diagnosis
• Peripheral arthritis: asymmetric oligoarthritis that typically involves
the knees, ankles, and occasionally the upper extremities,
usually parallels bowel disease in activity
• Spondylitis: clinically identical to ankylosing spondylitis; HLAB27
antigen present in most patients in a male: female ratio of 4:1
• Articular features may precede intestinal symptoms, especially in
Crohn's disease
• Extra-articular manifestations may also occur in Crohn's disease
(erythema nodosum) and in ulcerative colitis (pyoderma
gangrenosum)
• Differential Diagnosis
• Reactive arthritis
• Ankylosing spondylitis
• Psoriatic arthritis
• Rheumatoid arthritis
• Treatment
• Treat underlying intestinal inflammation
• Aspirin, other NSAlDs (eg, indomethacin, 50 mg three times
daily)
• Physical therapy for spondylitis
• Pearl
The younger the patient, the less the gastrointestinal complaints; thus,
arthritis in adolescence should prompt a searchfor inflammatory bowel
disease despite absence ofsymptoms.
Reference
De Keyser F et aI: Bowel inflammation and the spondyloarthropathies. Rheum
Dis Clin North Am 1998;24:785. [PMJD: 9891711]
166 Essentials of Diagnosis & Treatment
Septic Arthritis (Nongonococcal Acute
Bacterial Arthritis)
• Essentials of Diagnosis
• Acute pain, swelling, erythema, warmth, and limited movement
ofjoints
• Typically monarticular; knee, hip, wrist, shoulder, or ankle most
often involved
• fnfection usually occurs via hematogenous seeding of the synovium
• Previous joint damage and intravenous drug abuse predispose
• Most common organisms: Staphylococcus aureus, group A streptococci,
Escherichia coli, and Pseudomonas aeruginosa; Haemophilus
infiuenzae in children under 5; Staphylococcus epidermidis
following arthroscopy or joint surgery
• White cell count in synovial fluid > 100,000/~L; synovial fluid
culture positive in 50-75%, blood culture in 50%
• Differential Diagnosis
• Gonococcal arthritis
• Microcrystalline synovitis
• Rheumatoid arthritis
• Still's disease
• Infective endocarditis (may be associated)
• Treatment
• Intravenous antibiotics should be administered empirically
• Surgical evaluation for drainage and irrigation of the knee
• Affected hip joint usually requires surgical drainage
• Rest, immobilization, and elevation
• Removal of prosthetic joint
• Pearl
Pneumococcal arthritis in the absence of pneumonia or endocarditis
means multiple myeloma until proved otherwise.
Reference
Carreno Perez L: Septic anhritis. Baillieres Best Pract Res Clin Rheumatol
1999;13:37. [PMlD: 10052848]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 167
Gonococcal Arthritis
• Essentials of Diagnosis
• Most common in young women during menses or pregnancy
• Tenosynovitis in many joints followed by monarticular arthritis
• Characteristic purpuric skin lesions on the distal extremities
• White cell count in synovial fluid 50,OOO/IlL; synovial fluid Gram
stain and culture uncommonly positive; likewise blood cultures
Urethral, cervical, throat, skin lesion and rectal cultures on chocolate
or Thayer-Martin agar for Neisseria gonorrhoeae have higher
yield, may be positive in the absence of symptoms
• Recurrent disseminated gonococcal infection seen with congenital
complement component deficiencies
• Differential Diagnosis
• Nongonococcal bacterial arthritis
• Reactive arthritis
• Lyme disease
• Sarcoidosis
• Infecti ve endocarditis
• Meningococcemia with arthritis
Seronegative spondyloarthropathy
• Treatment
• Obtain YDRL, consider my testing
• Intravenous ceftriaxone or ceftizoxime for 7 days followed by
oral cefixime or ciprofloxacin
• Daily reaspiration of the synovial fluid if it reaccumulates
• Pearl
Surprisingly trivial destructive articular changes for a bacterial arthritis.
Reference
Cucurull E et al: Gonococcal arthritis. Rheum Dis Clin North Am 1998;
24:305. [pMlD: 9606761]
168 Essentials of Diagnosis &Treatment
+
Infectious Osteomyelitis
• Essentials of Diagnosis
• Infection usually occurs via hematogenous seeding of the bone;
metaphyses of long bones and vertebrae most frequently involved
• Subacute, vague pain and tenderness of affected bone or back with
little or no fever in adults; more acute presentation in children
• Organisms include Staphylococcus aureus, coagulase-negative
staphylococci, group A streptococci, gram-negative rods, anaerobic
and polymicrobial infections, tuberculosis, brucellosis,
histoplasmosis, coccidioidomycosis, blastomycosis
• Blood cultures may be positive; aspiration or biopsy of bone is
diagnostic
• Radiographs early in the course are often negative, but periarticular
demineralization, erosion of bone, and periosti tis may occur
later
• Radionuclide bone scan is 90% sensitive and may be positive
within 2 days after onset of symptoms
• Differential Diagnosis
• Acute bacterial arthritis
• Rheumatic fever
• Cellulitis
• Multiple myeloma
• Ewing's sarcoma
• Metastatic neoplasia
• Treatment
• Intravenous antibiotics after appropriate cultures have been obtained
• Oral ciprofloxacin, 750 mg twice daily for 6-8 weeks, may be
effective in limited osteomyelitis
• In older patients, treat with broad-spectrum antibiotics as for a
gram-negative hacteremia as a consequence of urinary, hiliary,
intestinal, and lower respiratory infections
• Debridement if response to antibiotics is poor
• Pearl
In re chronic osteomyelitis: once an osteo, always an osteo.
Reference
Lew DP et al: Osteomyelitis. N Engl J Med 1997;336:999. [PMID: 9077380]
Chapter 6 Rheumatologic & Autoimmune Disorders 169
Eosinophilic Fasciitis
• Essentials of Diagnosis
• Occurs predominantly in men
• Pain, swelling, stiffness, and tenderness of the hands, forearms,
feet, or legs evolving to woody induration and retraction of subcutaneous
tissue within days to weeks
• Associated with peripheral eosinophilia, polyarthralgias, arthritis,
carpal tunnel syndrome; no Raynaud's phenomenon
• Biopsy of deep fascia is diagnostic
• Association with aplastic anemia, thrombocytopenia
• Differential Diagnosis
• Systemic sclerosis
• Eosinophilia myalgia syndrome
• Hypothyroidism
• Trichinosis
• Mixed connective tissue disease
• Treatment
• NSAlOs
• Short course of corticosteroids
• Antimalarials
• Pearl
Perhaps the only systemic disease in medicine confined strictly to the
fascia.
Reference
Varga J et al: Eosinophilia-myalgia syndrome, eosinophilic fasciitis, and related
fibrosing disorders. Curr Opin Rheumatol 1997;9:562. [PMID: 9375286]
+
170 Essentials of Diagnosis & Treatment
Fibrositis (Fibromyalgia)
• Essentials of Diagnosis
• Most frequent in women ages 20-50
• Chronic aching pain and stiffness of trunk and extremi ties, especially
around the neck, shoulder, low back, and hips
• Must have 11 of 18 bilateral tender points: occiput, low cervical,
trapezius, supraspinatus, second rib at costochondral junction,
lateral epicondyle, gluteal region, greater trochanter, and medial
fat pad of the knee
• Associated with fatigue, headaches, subjective numbness, sleep
disorders, irritable bowel symptoms, and history of sexual or
domestic abuse
• Absence of objective signs of inflammation; normal laboratory
studies, including erythrocyte sedimentation rate
• Differential Diagnosis
• Chronic fatigue syndrome
• Rheumatoid arthritis
• SLE
• Depression
• Polymyalgia rheumatica
• HIY disease
• Treatment
• Patient education, supportive care, exercise programs
• Aspirin, other NSAlDs
• Tricyclics, cyclobenzaprine, chlorpromazine
• Injection of trigger points with corticosteroids
• Pearl
A tender point is defined as pain elicited with application of 4 kg 0
pressure, the same amount required to cause a fingernail to blanch.
Reference
Leventhal LJ: Management of fibromyalgia. Ann Intern Med 1999;131:850.
[PMJD: 10610631]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 171
Amyloidosis
• Essentials of Diagnosis
• A group of disorders characterized by deposition in tissues of
ordinarily soluble peptides
Amyloid protein (with characteristic green birefringence under
polarizing microscope after Congo red staining) may be found on
biopsy of rectal mucosa, gingival mucosa, bone marrow, or aspiration
of abdominal fat pad
• May be primary (idiopathic or myeloma-associated), familial,
localized, or secondary to familial Mediterranean fever, chronic
infectious or inflammatory disease, aging, hemodialysis; in each,
a different protein is responsible
• Distribution depends on type of amyloid; most systemic, but
localized amyloid found in Alzheimer's plaques, islet cells in diabetics,
carpal ligaments in dialysis patients
• Associated variably and unpredictably with peripheral neuropathy,
postural hypotension, nephrotic syndrome, cardiomyopathy,
arrhythmias, esophageal hypomotility, hepatosplenomegaly,
gastrointestinal malabsorption and obstruction, carpal tunnel syndrome,
macroglossia, arthropathy, endocrine gland insufficiency,
respiratory failure, cutaneous lesions, and ecchymoses
• M-spike in primary amyloidosis
• Differential Diagnosis
• Hemochromatosis
Sarcoidosis
Waldenstrom's macroglobulinemia
• Metastatic neoplasm
• Other causes of nephrotic syndrome
• Treatment
• Colchicine to prevent attacks of familial Mediterranean fever
when present
• Melphalan, prednisone if myeloma-associated
• Treat underlying disease if present
• Pearl
The combination ofnephrotic syndrome and hepatosplenomegaly in a
middle-aged patient is amyloidosis; only rarely can other single processes
do it.
Reference
Gertz MA et al: Amyloidosis. Hematol Oneol Clin North Am 1999;13: 121!.
PMlD: 10626146]
+
172 Essentials of Diagnosis & Treatment
Reflex Sympathetic Dystrophy
• Essentials of Diagnosis
• Usually follows direct trauma to the hand or foot, knee injury,
stroke, peripheral nerve injury, or arthroscopic knee surgery
• Severe pain and tenderness, most commonly of the hand or foot,
associated with vasomotor instability, skin atrophy, and hyperhidrosis
• Shoulder-hand variant with restricted ipsilateral shoulder movement
common after neck or shoulder injuries or following myocardial
infarction
• Characteristic disparity between degree of injury (usually modest)
and degree of pain (debilitating)
• Triple phase bone scan reveals increased uptake in the early phases
of the disease; radiographs show severe osteopenia (Sudeck's atrophy)
late in the course
• Differential Diagnosis
• Rheumatoid arthritis
• Polymyositis
• Scleroderma
• Gout, pseudogout
• Acromegaly
• Multiple myeloma
• Osteoporosis due to other causes
• Treatment
• Supportive care
• Physical therapy
• Active and passive exercises combined with benzodiazepines
• Stellate ganglion or lumbar sympathetic block
• Short course of corticosteroids given early in course
• Pearl
Afar more common disorder when prolonged bed rest was prescribed
for myocardial infarction.
Reference
Lopez RF: Reflex sympathetic dystrophy. Timely diagnosis and treatment can
prevent severe contractures. Postgrad Med 1997;10 J: 185. [PMTD: 9 J2621 J]
+
Chapter 6 Rheumatologic & Autoimmune Disorders 173
Carpal Tunnel Syndrome
• Essentials of Diagnosis
• The most common entrapment neuropathy, caused by compression
of median nerve (which innervates the flexor muscles of the
wrist and fingers)
• Middle aged women and those with a history of repetitive use of
the hands commonly affected
• Pain classically worse at night and exacerbated by hand movement
• Initial symptoms of pain or paresthesias in thumb, index, middle,
and lateral part of ring finger; progression to thenar eminence
wasting
• Pain radiation to forearm, shoulder, neck, chest, or other fingers
of the hand not uncommon
• Positive Tinel sign
• Usually idiopathic; common secondary causes include rheumatoid
arthritis, amyloidosis involving carpal ligament, sarcoidosis,
hypothyroidism, diabetes, pregnancy, acromegaly, gout
Diagnosis is primarily clinical; electrodiagnostic testing (assessing
nerve conduction velocity) helpful in some
• Differential Diagnosis
• C6 or C7 cervical radiculopathy
• Thoracic outlet syndrome leading to brachial plexus neuropathy
Mononeuritis multiplex
Syringomyelia
• Multiple sclerosis
• Angina pectoris, especially when left-sided
• Treatment
• Conservative measures initially, including hand rest, splinting,
anti-inflammatory medications
• Steroid injection into the carpal tunnel occasionally
• Surgical decompression in a few; hest done prior to development
of thenar atrophy
• Pearl
When obtaining a history ofann pain, rememher that carpal tunnel syndrome
affects the radial three and one-half fingers and myocardial
ischemia the ulnar one and one-half-and hope it's the right ann.
Reference
Whitley 1M et al: Carpal tunnel syndrome. A guide to prompt intervention. Postgrad
Med 1995;97:89. [pMID: 7816719]
7
Endocrine Disorders
Panhypopituitarism
• Essentials of Diagnosis
• Sexual dysfunction, weakness, easy fatigability; poor resistance
to stress, cold, or fasting; axillary and pubic hair loss
• Hypotension, often orthostatic; visual field defects if pituitary
tumor present
• Deficient cortisol response to ACTH; low serum T4 with low or
low-normal TSH; serum prolactin level may be elevated
• Low serum testosterone in men; amenorrhea; FSH and LH are
low or low-normal
• MRI may reveal a pituitary or hypothalamic lesion
• Differential Diagnosis
• Anorexia nervosa or severe malnutrition
• Hypothyroidism
• Addison's disease
• Cachexia due to other causes (eg, carcinoma or tuberculosis)
• Empty sella syndrome
• Treatment
• Surgical removal of pituitary tumor if present; pituitary irradiation
may be necessary for residual tumor but increases likelihood
of permanent hypopituitarism
• Lifelong endocrine replacement therapy with corticosteroids, thyroid
hormone, sex hormones, and, if indicated, growth hormone
• Pearl
In a woman with panhypopituitarism, ask about a previous complicated
pregnancy with postpartum bleeding; it could be Sheehan's syndrome.
Reference
Lissett CA et al: Management of pituitary tumours: strategy for investigation and
follow-up. Harm Res 2000;53(Supp13):65. [PMID: 10971108]
174
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 7 Endocrine Disorders 175
Acromegaly &Gigantism
+
• Essentials of Diagnosis
• Amenorrhea, headaches, excessive sweating
• Excessive growth of hands (increased glove size), feet (increased
shoe size), jaw (protrusion of lower jaw), face, and tongue;
gigantism if prior to epiphysial closure; visual field loss, coarse
facial features, deep voice
• Hyperglycemia, hypogonadotropic hypogonadism
• Elevated serum insulin-like growth factor- I (IGF-l)
• Elevated serum growth hormone with failure to suppress after an
oral glucose load
• Radiographic findings include enlarged sella, thickened skull,
and terminal phalangeal tufting; MRI demonstrates pituitary
tumor in 90%
• Differential Diagnosis
• Physiologic growth spun
• Pseudoacromegaly
• Familial coarse features
• Myxedema
• Treatment
• Transsphenoidal resection of adenoma is successful in many
patients; medical therapy is necessary for those with residual
disease
• The majority of patients respond to treatment with somatostatin
analogs (eg, octreotide)
• Dopamine agonists (eg, bromocriptine, cabergoline) occasionally
reduce growth hormone secretion
• Pituitary irradiation may be necessary if patients are not cured by
surgical and medical therapy
• Residual panhypopituitarism may require hormonal replacement
(humout acromegaly)
• Pearl
Peifect application of the wallet biopsy: compare present appearance
ofthe patient with photograph on the driver's license and you make the
diagnosis.
Reference
Melmed S et al: Current treatment guidelines for acromegaly. J Clin Endocrinol
Metab 1998;83:2646. [pMID: 9709926]
+
176 Essentials of Diagnosis & Treatment
Hyperprolactinemia
• Essentials of Diagnosis
• Women: menstrual disturbance (oligomenorrhea, amenorrhea),
galactorrhea, infertility
• Men: hypogonadism; decreased libido and erectile dysfunction;
galactorrhea; infertility
• Serum prolactin usually> 100 ng/mL
• May be caused by primary hypothyroidism
• Pituitary adenoma often demonstrated by MRl
• Differential Diagnosis
• Primary hypothyroidism
• Use of prolactin-stimulating drugs
• Pregnancy or lactation
• Hypothalamic disease
• Cirrhosis; renal failure
• Chronic nipple stimulation; chest wall injury
• Treatment
• Dopamine agonists (eg, bromocriptine or cabergoline) usually
shrink pituitary adenoma and restore fertility
• Transsphenoidal resection for large tumors and for those causing
visual compromise or refractory to dopamine agonists
• Pearl
Virtually every psychotropic drug causes hyperprolactinemia.
Reference
Kaye TB: Hyperprolactinemia. Causes, consequences, and treatment options.
Postgrad Med 1996;99:265. [PMID: 8650091]
Chapter 7 Endocrine Disorders 177
Diabetes Insipidus
+
• Essentials of Diagnosis
• Polyuria with volumes of 2-20 LId; polydipsia, intense thirst
• Serum osmolality> urine osmolality
• Urine specific gravity usually < 1.006 during ad libitum fluid intake
• Inability to concentrate urine with fluid restriction, resulting in
hypematremia
• Central diabetes insipidus (vasopressin-deficient) caused by hypothalamic
or pituitary disease
• Nephrogenic diabetes insipidUS (vasopressin-resistant) may be
familial or caused by lithium, chronic renal disease, hypokalemia,
hypercalcemia, tetracycline _
• Vasopressin challenge establishes central cause
• Differential Diagnosis
• Psychogenic polydipsia
• Osmotic diuresis
• Diabetes mellitus
• Beer potomania
• Treatment
• Ensure adequate free water intake
• Intranasal desmopressin acetate for central diabetes insipidus
• Hydrochlorothiazide or indomethacin for nephrogenic diabetes
insipidUS
• Pearl
Demeclocycline and other tetracyclines cause permanent if subtle
nephrogenic diabetes insipidus; be cautious using them for acne during
puberty.
Reference
Singer I et al: The management of diabetes inSipidus in adults. Arch Intern Med
1997;157:1293. [PMlD: 9201003]
178 Essentials of Diagnosis & Treatment
Simple & Nodular Goiter
• Essentials of Diagnosis
• Single or multiple thyroid nodules found on thyroid palpation
• Large multinodular goiters may be associated with compressive
symptoms (dysphagia, stridor)
• Measurement of free thyroxine (Fr4) and TSH; radioiodine
uptake scan helpful in selected cases for distinguishing cold from
hot nodules
• Differential Diagnosis
• Graves' disease (diffuse toxic goiter)
• Autoimmune thyroiditis
• Carcinoma of the thyroid
• Treatment
• Fine-needle biopsy for single or dominant nodules; carcinomas
or suspicious cold lesions require surgery
• Levothyroxine treatment suppresses growth in benign nodules or
multinodular goiter and may cause regression; contraindicated if
TSH is low
• Surgery for severe compressive symptoms
• Pearl
Pharmacologic iodine, as in contrast-enhanced radiographic studies,
may result in hyperthyroidism via thejodbasedow phenomenon.
Reference
Hermus AR et al: Treatment of benign nodular thyroid disease. N Engl J Med
1998;338:1438. [PMID: 9589652]
Chapter 7 Endocrine Disorders 179
+
Adult Hypothyroidism &Myxedema
• Essentials of Diagnosis
• Cold intolerance, constipation, weight gain, hoarseness, altered
mentation, depression, hypermenorrhea
• Hypothermia, bradycardia, dry skin with yellow tone (carotenemia);
nonpitting edema; macroglossia; delayed relaxation of
deep tendon reflexes
• Low serum Ff4 ; TSH elevated in primary hypothyroidism; macrocytic
anemia
• Myxedema coma may be associated with obtundation, profound
hypothennia, hypoventilation, hypotension, striking bradycardia;
pleural and pericardial effusions
• Associated with other autoimmune endocrinopathies
• Differential Diagnosis
• Chronic fatigue syndrome
• Congestive heart failure
• Primary amyloidosis
• Depression
• Exposure hypothermia
• Parkinson's disease
• Treatment
• Levothyroxine replacement starting with low doses and increasing
gradually until euthyroid
• Treat myxedema coma with intravenous levothyroxine; if adrenal
insufficiency is suspected, add intravenous hydrocortisone
• Pearl
Treating myxedema may precipitate ad.disonian crisis because of subclinical
concomitant adrenal instif./iciency; add steroids to thyroid hormone
until adrenocortical insufficiency has been ruled out.
Reference
Woeber, KA. Update on the management of hyperthyroidism and hypothyroidism.
Arch Intern Med 2000;160:1067, [PMID: 10789598]
+
180 Essentials of Diagnosis & Treatment
Hyperthyroidism
• Essentials of Diagnosis
• Sweating, weight loss, heat intolerance, irritability, weakness,
increased number of bowel movements, menstrual irregularity
• Sinus tachycardia or atrial fibrillation, tremor, warm moist skin,
eye findings (stare, lid lag); diffuse goiter, thyroid bruit and exophthalmos
in Graves' disease
• Serum Ff4 and T3 increased; TSH low or undetectable
• Radioiodine uptake scan will differentiate Graves' disease, toxic
nodule, and thyroiditis; may also be useful in ectopic thyroid tissue
(ovary)
• Thyroid-stimulating immunoglobulin and thyroid autoantibodies
are often positive in Graves' disease; common association with
other endocrine gland autoantibodies
• Differential Diagnosis
• Anxiety, neurosis, or mania
• Pheochromocytoma
• Exogenous thyroid administration
• Catabolic illness
• Chronic alcoholism
• Treatment
• Supportive care for patients with thyroiditis
• Propranolol for symptomatic relief of catecholamine-mediated
symptoms
• Antithyroid drugs (methimazole or propylthiouracil) for patients
with mild Graves' disease or smaller goiters
• Radioactive iodine ablation is indicated for more severe or refractory
Graves' disease (contraindicated in pregnancy) and in patients
with toxic nodular disease; in older patients or those with
severe hyperthyroidism, treat first with antithyroid drugs
• Suhtotal thyroidectomy for failure of medical therapy if radioactive
iodine is contraindicated (eg, pregnancy) or for very large
nodular goiters; euthyroid state should be achieved medically
before surgery
• Pearl
In patients over 60, when you think it's hyperthyroidism it's hypo- and
when you think it's hypo- it's hyper-: the diseases become increasingly
atypical with age.
Reference
Lazarus JH: Hyperthyroidism. Lancet 1997;349:339. [PMlD: 9024389]
Chapter 7 Endocrine Disorders 181
Thyroiditis
+
• Essentials of Diagnosis
• Painful enlarged thyroid gland in acute and subacute forms; painless
enlargement in chronic form
• Generally classified as chronic lymphocytic (Hashimoto's) thyroiditis
and subacute (granulomatous) thyroiditis; suppurative
thyroiditis and Riedel's thyroiditis are uncommon
• Thyroid function tests variable, with serum T4 and T3 1evels often
high in acute forms and low in chronic disease
• Elevated erythrocyte sedimentation rate and reduced radioiodine
uptake in subacute thyroiditis
• Thyroid autoantibodies positive in Hashimoto's thyroiditis
• Differential Diagnosis
• Endemic goiter
• Graves' disease (diffuse toxic goiter)
• Carcinoma of the thyroid
• Pyogenic infections of the neck
• Treatment
• Antibiotics for suppurative thyroiditis
• Nonsteroid anti-inflammatory drugs for subacute thyroiditis; prednisone
in severe cases; symptomatic treatment with propranolol
• Levothyroxine replacement for Hashimoto's thyroiditis
• Partial thyroidectomy for local severe pressure or adhesions in
Riedel's thyroiditis
• Pearl
The patient can be hyper-, hypo-, or euthyroid depending on where the
disease is when you test.
Reference
SlalOsky J et at: Thyroiditis: differential diagnosis and management. Am Fam
Physician 2000;61:1047. [PMID: 10706157]
+
182 Essentials of Diagnosis &Treatment
Hypoparathyroidism
• Essentials of Diagnosis
• Tetany, carpopedal spasms, tingling of lips and hands; altered
mentation
• Positive Chvostek sign (facial muscle contraction on tapping the
facial nerve) and Trousseau phenomenon (carpal spasm after
application of arm cuff); dry skin and brittle nails; cataracts
• Serum calcium low; serum phosphate high; serum parathyroid hormone
low to absent
• Long ST segment resulting in long QT interval on ECG
• History of previous thyroidectomy or neck surgery in patients
with surgical hypoparathyroidism
• Differential Diagnosis
• Pseudohypoparathyroidism
• Vitamin D deficiency syndromes
• Acute pancreatitis
• Hypomagnesemia
• Chronic renal failure
• Hypoalbuminemia
• Treatment
• For acute tetany, intravenous calcium gluconate, followed by oral
calcium carbonate and vitamin D derivatives
• Correct concurrent hypomagnesemia
• Chronic therapy includes high-calcium diet in addition to calcium
and vitamin D supplements
• Avoid phenothiazines (prolonged QT) and furosemide (increases
symptoms of hypocalcemia)
• Pearl
Radiotherapy causes hypothyroidism but never hypoparathyroidismthe
parathyroids are among the most resistal1l tissues in the body to
radiation.
Reference
Rude RK: Hypocalcemia and hypoparathyroidism. Curr Ther Endocrinol Metab
1997;6:546. [PMlD: 9174804]
Chapter 7 Endocrine Disorders 183
+
Primary Hyperparathyroidism
• Essentials of Diagnosis
• Renal stones, bone pain, mental status changes, constipation
("stones, bones, moans, and abdominal groans"), polyuria; many
patients are asymptomatic
• Serum and urine calcium elevated; low-nonnal to low serum phosphate;
high-nonnal or elevated serum parathyroid honnone level;
alkaline phosphatase often elevated
• Bone radiographs show cystic bone lesions (brown tumors) and
subperiosteal resorption ofcortical bone, especially the phalanges
(osteitis fibrosa cystica); may have osteoporosis and pathologic
fractures
• History of renal stones, nephrocalcinosis, recurrent peptic ulcer
disease, or recurrent pancreatitis may be present
• Differential Diagnosis
• Familial hypocalciuric hypercalcemia
• Hypercalcemia of malignancy
• Renal failure
• Vitamin D intoxication or milk-alkali syndrome
• Sarcoidosis, granulomatous disorders
• Hyperthyroidism
• Multiple myeloma
• Treatment
Parathyroidectomy for patients with symptomatic disease,
markedly elevated calcium level, hypercalciuria, kidney stones,
or bone disease
• Bisphosphonates (eg, pamidronate) for acute treatment of severe
hypercalcemia while preparing for surgery
• For patients with mild asymptomatic disease: maintain adequate
fluid intake and avoid immobilization, thiazide diuretics, and
calcium-containing antacids; follow for disease progression
• Estrogen replacement for postmenopausal women
• Pearl
The natural history ofuntreated hyperparathyroidism is benign; even
superb centers have trouble obtaining follow-up ofpatients-because
they do so well.
Reference
aI Zahrani A et al: Primary hyperparathyroidism. Lancet 1997;349: 1233. [PMID:
9130957]
+
184 Essentials of Diagnosis & Treatment
Osteoporosis
• Essentials of Diagnosis
• Asymptomatic or associated with back pain from vertebral fractures;
loss of height; kyphosis
• Demineralization of spine, hip, and pelvis by radiograph; vertebral
compression fractures; spontaneous fractures often discovered
incidentally
• Bone mineral density more than 2.5 SD below the average value
for a young adult
• Differential Diagnosis
• Osteomalacia
• Multiple myeloma
• Metastatic carcinoma
• Hypophosphatemic disorders
• Osteogenesis imperfecta
• Secondary osteoporosis due to steroids, hyperthyroidism, hypogonadism,
alcoholism. or liver disease
• Treatment
• Diet adequate in calcium and vitamin D with supplements to
achieve 1000-1500 mg elemental calcium and 400 1U vitamin D
daily
• Regular exercise
• Fall prevention strategies
• Effective antiresorptive therapies include bisphosphonates (eg,
alendronate. risedronate), estrogen replacement therapy, calcitonin,
and selective estrogen receptor modulators (SERMS), eg,
raloxifene
• Men with hypogonadism are treated with testosterone
• Pearl
Easily the most debilitating nonmalignant disease ofbone.
Reference
Lambing CL: Osteoporosis prevention, detection. and treaunent. A mandate for
primary care physicians. Postgrad Med 2000;107:37. [pMID: 10887444]
Chapter 7 Endocrine Disorders 185
+
Paget's Disease (Osteitis Deformans)
• Essentials of Diagnosis
• Often asymptomatic or associated with bone pain, fractures, and
bone deformity (bowing, kyphosis)
• Serum calcium and phosphate normal; alkaline phosphatase elevated;
urinary hydroxyproline elevated
• Dense, expanded bones on x-ray resulting from accelerated bone
turnover and disruption of normal architecture; osteolytic lesions
in the skull and extremities; vertebral fractures; fissure fractures
in the long bones
• May have neurologic sequelae due to nerve compression as
pagetic bones enlarge (eg, deafness)
• Differential Diagnosis
• Osteogenic sarcoma
• Multiple myeloma
• Fibrous dysplasia
• Metastatic carcinoma
• Osteitis fibrosa cystica (hyperparathyroidism)
• Treatment
• No treatment for asymptomatic patients
• Treat symptomatic disease with inhibitors of osteoclastic resorption
(bisphosphonates or calcitonin)
• The role of prophylactic treatment to prevent bone deformities or
neurologic sequelae is not well established
• Pearl
Was Paget's disease the cause ofBeethoven's deafness? Only his pictures
suggest it. as no alkaline phosphatase detenninations were available
between 1770 and 1828.
Reference
Delmas PO et al: The management of Paget's disease of bone. N Engl J Med
1997;336:558. [PMlD: 9023094]
+
186 Essentials of Diagnosis & Treatment
Primary Adrenal Insufficiency (Addison's Disease)
• Essentials of Diagnosis
• Weakness, anorexia, weight loss, abdominal pain, nausea and
vomiting; increased skin pigmentation
• Hypotension, dehydration; postural symptoms
• Hyponatremia, hyperkalemia, hypoglycemia, lymphocytosis, and
eosinophilia; increased serum urea nitrogen and calcium may be
present
• Serum cortisol levels low to absent and ACTH elevated; cortisol
level fails to rise after cosyntropin (ACTH) stimulation
• Often associated with other autoimmune endocrinopathies; may
also be due to trauma, infection (especially tuberculosis, histoplasmosis),
adrenal hemorrhage, or adrenoleukodystrophy
• Differential Diagnosis
• Secondary adrenal insufficiency
• Anorexia nervosa
• Malignancy
• Infection
• Salt-wasting nephropathy
• Hemochromatosis
• Treatment
• In acute adrenal crisis, treat immediately with intravenous hydrocortisone
(100 mg intravenously every 8 hours) once the diagnosis
is suspected; provide appropriate volume resuscitation and
blood pressure support; consider empiric antibiotics
• In chronic adrenal insufficiency, maintenance therapy includes
glucocorticoids (hydrocortisone) and mineralocorticoids (ftudrocortisone)
• Increase glucocorticoid dose for trauma, surgery, infection, or
stress
• Pearl
If the systolic blood pressure is over 100 mm Hg, consider other diseases.
Reference
Oelkers W: Adrenal insufficiency. N Engl J Med 1996;335:1206. [PMID:
8815944]
Chapter 7 Endocrine Disorders 187
+
Hypercortisolism (Cushing's Syndrome)
• Essentials of Diagnosis
• Weakness, muscle wasting, weight gain, central obesity, psychosis,
hirsutism, acne, menstrual irregularity, hypogonadism
• Hypertension, moon facies, buffalo hump, thin skin, easy bruisability,
purple striae, poor wound healing, osteoporosis
• Hyperglycemia, glycosuria, leukocytosis, lymphocytopenia; may
have hypokalemia with ectopic ACTH secretion
• Elevated plasma cortisol and urinary free cortisol; failure to suppress
plasma cortisol with exogenous dexamethasone (overnight
low-dose dexamethasone test)
• A normal or high ACTH level indicates ACTH-dependent Cushing's
disease (pituitary adenoma or ectopic ACTH syndrome); a
low ACTH level indicates adrenal tumor
• CT or MRI will reveal adrenal tumor if present
• Differential Diagnosis
• Chronic alcoholism
• Depression
• Diabetes mellitus
• Exogenous glucocorticoid administration
• Severe obesity
• Treatment
• Transsphenoidal resection of pituitary adenoma if present; radiation
therapy for residual disease
• Resection of adrenal tumor if present
• Resection of ectopic ACTH-producing tumor if able to localize
(eg, carcinoid, prostate small-cell)
• Ketoconazole or metyrapone to suppress cortisol in unresectable
cases
• Bilateral adrenalectomy for adrenal hyperplasia in refractory
cases of ACTH-dependent Cushing's syndrome
• Pearl
If you see the above picture in a man, the cortisol isn't from classic
Cushing's syndrome; the incidence is 10: I women to men.
Reference
Kirk LF Jr et al: Cushing's disease: clinical manifestations and diagnostic evaluation.
Am Fam Physician 2000;62: 1119. [PMID: 10997535]
+
188 Essentials of Diagnosis &Treatment
Hirsutism &Virilizing Diseases of Women
• Essentials of Diagnosis
• Menstrual disorders, hirsutism, acne
• Virilization may occur: increased muscularity, balding, deepening
of the voice, enlargement of the clitoris
• Occasionally a pelvic mass is palpable
• Serum testosterone and androstenedione often elevated; serum
DHEAS elevated in adrenal disorders
• May be due to polycystic ovary syndrome, congenital adrenal
hyperplasia, ovarian or adrenal tumors, ACTH-dependent Cushing's
syndrome
• Differential Diagnosis
• Familial, idiopathic, or drug-related hirsutism
• Cushing's syndrome
• Exogenous androgen ingestion
• Treatment
• Surgical removal of ovarian or adrenal tumor if present
• Oral contraceptives to suppress ovarian androgen excess and normalize
menses
• GJucocorticoids for congenital adrenal hyperplasia
• Spironolactone and cyproterone acetate to ameliorate hirsutism;
finasteride and ftutamide may help in refractory cases
• Consider metformin for women with polycystic ovary syndrome
• Pearl
Check the drug history in hirsutism-it's more likely than the above
syndromes.
Reference
Rittmaster RS: Hirsutism. Lancet 1997;349: 19 J. [PMJD: 91 J 1556]
Chapter 7 Endocrine Disorders 189
Male Hypogonadism
+
• Essentials of Diagnosis
• Diminished libido and impotence
• Sparse growth of male body hair
• Testes may be small or normal in size; serum testosterone is usually
decreased
• Serum gonadotropins (LH and FSH) are decreased in hypogonadotropic
hypogonadism; they are increased in primary testicular
failure (hypergonadotropic hypogonadism)
• Causes of hypogonadotropic hypogonadism include chronic illness,
malnutrition, drugs, pituitary tumor, Cushing's syndrome,
congenital syndromes, and Kallman's disease
• Causes of hypergonadotropic hypogonadism include Klinefelter's
syndrome, bilateral anorchia, testicular trauma, orchitis, and myotonic
dystrophy
• Differential Diagnosis
• Cushing's syndrome
• Hemochromatosis
• Pituitary tumor
• Androgen insensitivity
• Treatment
• Evaluate and treat underlying disorder
• Testosterone replacement (intramuscular or transdermal)
• Pearl
One ofthe reasons to check the first cranial nerve: mwsmia is afeature
ofKallman's syndrome.
Reference
Hayes FJ et aJ: Hypogonadotropic hypogonadism. Emerg Med Clin North Am
199827:7391. [PM1D: 9922906]
+
190 Essentials of Diagnosis &Treatment
Primary Hyperaldosteronism
• Essentials of Diagnosis
• Hypertension (usually mild), polyuria, fatigue, and weakness
• Hypokalemia, metabolic alkalosis
• Elevated plasma and urine aldosterone levels with suppressed
plasma renin level
• May be associated with adrenocortical adenoma (75%) or bilateral
adrenocortical hyperplasia (25%)
• Rarely due to glucocorticoid-remediable aldosteronism
• Adrenal mass often demonstrated by CT or MRl
• Differential Diagnosis
• Essential hypertension
• Periodic paralysis
• Congenital adrenal hyperplasia
• Pseudohyperaldosteronism; European licorice ingestion
• Chronic diuretic use or laxative abuse
• Unilateral renovascular disease
• Cushing's syndrome
• Treatment
• Surgical resection of unilateral adenoma secreting aldosterone
(Conn's syndrome)
• Spironolactone for bilateral adrenal hyperplasia; surgery does not
cure hypertension in these cases and is not generally recommended
• Dexamethasone for glucocorticoid-remediable aldosteronism
• Antihypertensive therapy as necessary
• Pearl
If the sodium is less than 140 mg/dL and a spot urine potassium less
than 40 mg/dL, consider something else.
Reference
Ganguly A: Primary aldosteronism. N Engl J Med 1998;339: 1828. [PM 10:
9854120]
Chapter 7 Endocrine Disorders 191
Pheochromocytoma
+
• Essentials of Diagnosis
• Paroxysmal or sustained hypertension; postural hypotension
• Episodes of perspiration, palpitations, and headache; anxiety,
nausea, chest or abdominal pain
Hypermetabolism with normal thyroid tests; hyperglycemia and
glycosuria may be present
• Elevated urinary catecholamines, metanephrines, and vanillylmandelic
acid are diagnostic; serum epinephrine and norepinephrine
elevated
• CT or MRI can confirm and localize pheochromocytoma;
123I-MIBG scan may help to localize tumors
• Differential Diagnosis
• Essential hypertension
• Thyrotoxicosis
• Panic attacks
• Preeclampsia-eclampsia
Acute intermittent porphyria
• Treatment
• Surgical removal of tumor or tumors
Alpha blockade with phenoxybenzamine prior to surgery
Beta-adrenergic receptor blockade can be added after effective
alpha blockade to help control tachycardia
Adequate volume replenishment mandatory prior to surgery
• Oral phenoxybenzamine or metyrosine for symptomatic treatment
in patients with inoperable tumors; metastatic pheochromocytoma
may be treated with chemotherapy or 131I-MIBG
• Pearl
Rule oftens: Approximately ten percent bilateral, ten percent malignant,
ten percent eXIra-adrenal, len percenlfamilial, ten percenlnormolensive.
Reference
Werbel 55 et al: Pheochromocytoma. Update on diagnosis, localization, and
management. Med Clin North Am 1995;79:131. [PMID: 7808088]
+
192 Essentials of Diagnosis & Treatment
Hypoglycemia in the Adult
• Essentials of Diagnosis
• Blurred vision, diplopia, headache, slurred speech, weakness,
sweating, palpitations, tremulousness, altered mentation; focal
neurologic signs common
• Plasma glucose <40 mg/dL
• Causes include alcoholism, postprandial hypoglycemia (eg, postgastrectomy),
insulinoma, medications (insulin, sulfonylureas,
pentamidine), adrenal insufficiency
• Differential Diagnosis
• Central nervous system disease
• Hypoxia
• Psychoneurosis
• Pheochromocytoma
• Treatment
• Intravenous glucose (oral glucose for patients who are conscious
and able to swallow)
• Intramuscular glucagon if no intravenous access available
• Treatment of underlying disease or removal of offending agent
(eg, alcohol, pentamidine, sulfonylureas)
• For patients with postprandial (reactive) hypoglycemia, eating
small frequent meals with reduced proportion of carbohydrates
may help
• Pearl
Remember neuroglycopenic hypoglycemia in hypothermia with altered
mental status.
Reference
Service, FJ. Hypoglycemic disorders. N Engl J Med 1995;332:1144. [PMID:
7700289]
Chapter 7 Endocrine Disorders 193
Type 1 Diabetes Mellitus
• Essentials of Diagnosis
• Crisp onset, no family history
• Polyuria, polydipsia, weight loss
• Fasting plasma glucose> 126 mg/dL; random plasma glucose
> 200 mg/dL with symptoms; glycosuria
• Associated with ketosis in untreated state; may present as medical
emergency (diabetic ketoacidosis)
• Long-term risks include retinopathy, nephropathy, neuropathy,
and cardiovascular disease
• Differential Diagnosis
• Nondiabetic glycosuria (eg, Fanconi's syndrome)
• Diabetes insipidus
• Acromegaly
• Cushing's disease or syndrome
• Pheochromocytoma
• Medications (eg, glucocorticoids, niacin)
• Treatment
• Insulin treatment is required
• Patient education is crucial, emphasizing dietary management,
intensive insulin therapy, self-monitoring of blood glucose, hypoglycemia
awareness, foot and eye care
• Pearl
The prognosis ofdiabetic ketoacidosis is better than that ofa nonketotic
hyperosmolar state (see page 196for why).
Reference
Havas S: Educational guidelines for achieving tight control and minimizing
complications of type I diabetes. Am Fam Physician 1999;60: 1985. [PMID:
10569502J
+
194 Essentials of Diagnosis & Treatment
Type 2 Diabetes Mellitus
• Essentials of Diagnosis
• Most patients are older and tend to be obese
• Gradual onset of polyuria, polydipsia; often asymptomatic
• Candidal vaginitis in women, chronic skin infection, generalized
pruritus, blurred vision
• Fasting plasma glucose> 126 mg/dL; random plasma glucose
> 200 mg/dL with symptoms; glycosuria; elevated glycosylated
hemoglobin (A1J; ketosis rare
• Family history often present; frequently associated with hypertension,
hyperlipidemia, and atherosclerosis
• May present as medical emergency (especially in the elderly) as
nonketotic hyperosmolar coma
• Long-term risks include retinopathy, nephropathy, neuropathy,
and cardiovascular disease
• Differential Diagnosis
• Nondiabetic glycosuria (eg, Fanconi's syndrome)
• Diabetes insipidus
• Acromegaly
• Cushing's disease or syndrome
• Pheochromocytoma
• Medications (eg, glucocorticoids, niacin)
• Severe insulin resistance syndromes
• Altered mental status due to other cause
• Treatment
• Patient education is important, emphasizing dietary management,
exercise, weight loss, self-monitoring of blood glucose, hypoglycemia
awareness, foot and eye care
• Mild cases may be controlled initially with diet, exercise, and
weight loss
• Oral hypoglycemic agents if diet is ineffective; insulin may he
required if combination oral agents fail
• Pearl
The cause of the most profound involuntary weight loss in medicine
with a normal physical examination.
Reference
DeFronzo RA: Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern
Med 1999;131:281. [PMTD: 10454950]
Chapter 7 Endocrine Disorders 195
Diabetic Ketoacidosis
+
• Essentials of Diagnosis
• Acute polyuria and polydipsia, marked fatigue, nausea and vomiting,
coma
• Fruity breath; dehydration, hypotension if severe volume depletion
occurs; Kussmaul respirations
• Hyperglycemia> 250 mg/dL, ketonemia, acidemia with blood
pH < 7.3 and serum bicarbonate < 15 meq/L, elevated anion gap;
glycosuria and ketonuria; total body potassium depleted despite
elevation in serum potassium
Due to insulin deficiency or increased insulin requirements in a
type I diabetic (eg, in association with myocardial ischemia,
surgery, infection, gastroenteritis, intra-abdominal disease, or
medical noncompliance)
• Differential Diagnosis
• Alcoholic ketoacidosis
• Uremia
• Lactic acidosis
• Sepsis
• Treatment
• Aggressive volume resuscitation with saline; dextrose should be
added to intravenous fluids once glucose reaches 250-300 mg/dL
• Intravenous regular insulin replacement with frequent laboratory
monitoring
• Potassium, magnesium, and phosphate replacement
• Identify and treat precipitating cause
• Pearl
Very low pH and severe hyperkalemia look bad and are bad, but osmolality
determines the outcome.
Reference
Kitabchi AR et al: Management of diabetic ketoacidosis. Am Fam Physician
1999;60:455. [PMTD: 10465221]
+
196 Essentials of Diagnosis & Treatment
Hyperosmotic Nonketotic Diabetic Coma
• Essentials of Diagnosis
• Gradual onset of polyuria, polydipsia, dehydration, and weakness;
in severe cases, may progress to obtundation and coma
• Occurs in patients with type 2 diabetes, typically in elderly patients
with reduced fluid intake
• Profound hyperglycemia (> 600 mg/dL), hyperosmolality (> 310
mosm/kg); pH > 7.3, serum bicarbonate> 15 meq/L; ketosis
and acidosis are usually absent
• Differential Diagnosis
• Cerebrovascular accident or head trauma
• Diabetes insipidus
• Hypoglycemia
• Hyperglycemia
• Treatment
• Aggressive volume resuscitation with normal saline until patient
euvolemic, then with hypotonic saline
• Regular insulin 15 units intravenously plus 15 units subcutaneously
initially is usually effective, followed by subcutaneous
insulin every 4 hours
• Careful monitoring of serum sodium, osmolality, and glucose
• Dextrose-containing fluids when glucose is 250-300 mg/dL
• Potassium and phosphate replacement as needed
• Pearl
Asfor diabetic ketoacidosis, osmolality determines the outcome; it's the
reason this condition's prognosis is worse than that of ketoacidosis,
where osmolality is usually normal.
Reference
Lorber D: Nonketotic hypertonicity in diabetes mellitus. Med Clin North Am
1995;79:39. [PMlD: 7808094]
Chapter 7 Endocrine Disorders 197
Gynecomastia
+
• Essentials of Diagnosis
• Glandular enlargement of the male breast
• Often asymmetric or unilateral and may be tender
• Nipple discharge may be present
• Common in puberty and among elderly men
• Multiple causes include obesity, androgen resistance, hyperprolactinemia,
hypenhyroidism, hypogonadism, chronic liver disease,
adrenal tumors, testicular tumors, bronchogenic carcinoma,
and drugs (eg, alcohol, amiodarone, diazepam, digoxin, isoniazid,
ketoconazole, marijuana, omeprazole, tricyclic antidepressants)
• Differential Diagnosis
• Associations noted above
• Benign or malignant tumors of the breast
• Treatment
• Careful testicular examination; chest x-ray to rule out bronchogenic
carcinoma; measurement of ~-hCG, LH, testosterone, and
estradiol may be indicated to rule out underlying disorder
• Needle biopsy of suspicious areas of breast enlargement
Remove offending drug or treat underlying condition; reassurance
if idiopathic
• Consider surgical correction for severe cases
• Pearl
Remember that 1% ofbreast carcinoma occurs in men.
Reference
Neuman JF: Evaluation and treatment of gynecomastia. Am Fam Physician
J997;55: J835 [PMlD: 9 J05209]
8
Inlee'lious Diseases
VIRAL INFECTIONS
Herpes Simplex
• Essentials of Diagnosis
• Recurrent grouped small vesicles on erythematous base, usually
perioral or peri genital
• Primary infection more severe and often associated with fever,
regional lymphadenopathy, and aseptic meningitis
• Recurrences precipitated by minor infections, trauma, stress, sun
exposure
• Oral and genital lesions highly infectious
• Systemic infection may occur in immunosuppressed patients
• Proctitis, esophagitis, and keratitis may complicate
• Direct fluorescent antibody or culture of ulcer can be diagnostic
• Differential Diagnosis
• Herpangina, hand-foot-and-mouth disease
• Aphthous ulcers
• Stevens-Johnson syndrome
• Bacterial infection of the skin
• Syphilis and other sexually transmitted diseases
• Other causes of encephalitis, proctitis, or keratitis
• Treatment
• Acyclovir, famciclovir, and valacyclovir may attenuate recurrent
course of genital or oral lesions and are obligatory for systemic
or central nervous system disease
• Pearl
In a smoker, a nonresolving "herpetic" ulcer on the lip suggests the
diagnosis ofsquamous cell cancer.
Reference
Whitley RJ et al: Herpes simplex viruses. Clin Infect Dis 1998;26:541. rPMID:
9524821]
198
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 8 Infectious Diseases 199
Measles (Rubeola)
+
• Essentials of Diagnosis
• An acute systemic viral illness transmitted by inhalation of infective
droplets
• Incubation period 10-14 days
• Prodrome of fever, coryza, cough, conjunctivitis, photophobia
• Progression of brick-red, irregular maculopapular rash 3 days
after prodrome from face to trunk to extremities
• Koplik's spots (tiny "table salt crystals") on the buccal mucosa
are pathognomonic but appear and disappear rapidly
• Leukopenia
• Encephalitis in 1-3%
• Differential Diagnosis
• Other acute exanthems (eg, rubella, enterovirus, Epstein-Barr virus
infection, varicella, roseola)
• Drug allergy
• Pneumonia or encephalitis due to other cause
• Treatment
• Primary immunization preventive after age 15 months; revaccination
of adults born after 1956 without documented immunity
recommended
• Isolation for 1 week following onset of rash
• Specific treatment of secondary bacterial complications
• Pearl
OJ all the viral exanthems, systemic toxicity is most marked with
measles.
Reference
Atkinson WL: Epidemiology and prevention of measles. Dermatol Clin 1995;
13:553. [pMlD: 7554503]
+
200 Essentials of Diagnosis & Treatment
Rubella
• Essentials of Diagnosis
• A systemic illness transmitted by inhalation of infected droplets,
with incubation period 14-21 days
• No prodrome in children (mild in adults); fever, malaise, coryza
coincide with eruption of fine maculopapular rash on face to trunk
to extremities which rapidly fades
• Arthralgias common, panicularly in young women
• Posterior cervical, suboccipital, and posterior auricular lymphadenopathy
5-10 days before rash
• Leukopenia, thrombocytopenia
• In one out of 6000 cases, postinfectious encephalopathy develops
1-6 days after the rash; mortality rate is 20%
• Differential Diagnosis
• Other acute exanthems (eg, rubeola, enterovirus, Epstein-Barr
virus infection, varicella)
• Drug allergy
• Treatment
• Active immunization after age 15 months; girls should be immunized
before menarche though not during pregnancy
• Symptomatic therapy only
• Pearl
Rubella-associated arthritis is more symptomatic after vaccination
than with natural infection.
Reference
Rasa C: Rubella and rubeola. Semin Perinatal J998;22:318. [pMTD: 9738996]
Chapter 8 Infectious Diseases 201
Cytomegalovirus Disease
+
• Essentials of Diagnosis
• Neonatal infection: hepatosplenomegaly, purpura, central nervous
system abnormalities
• Immunocompetent adults: mononucleosis-like illness characterized
by fever, myalgias, hepatosplenomegaly, leukopenia with
lymphocytic predominance, often following transfusion; no pharyngitis,
however
• Immunocompromised adults: retinitis (AIDS), pneumonia, meningoencephalitis,
polyradiculopathy, chorioretinitis, chronic diarrhea
Fever may be prolonged in the latter group
• In immunocompetent adults, IgM is diagnostic
In AIDS patients, funduscopic examination establishes the diagnosis;
culture positivity does not establish the etiology of any
symptom complex
• Differential Diagnosis
• Infectious mononucleosis (Epstein-Barr virus)
Acute HIV infection
• Other causes of prolonged fever (eg, lymphoma, endocarditis)
• In immunocompromised patients: other causes of atypical pneumonia,
meningoencephalitis, or chronic diarrhea
• In infants: toxoplasmosis, rubella, herpes simplex, syphilis
• Treatment
• Appropriate supportive care
Ganciclovir, foscarnet, or cidofovir intravenously in immunocompromised
patients
• Pearl
Acute cytomegalovirus irifection should always be considered in a patient
with a mononucleosis-like illness and a negative heterophil agglutination
test (Monospot), especially ifpharyngitis is absent.
Reference
Nichols WG: Recent advances in the therapy and prevention ofCMV infections.
J Clin Viml 2000;16:25. [PMID: 10680738]
+
202 Essentials of Diagnosis &Treatment
Varicella (Acute Chickenpox, Zoster [Shingles])
• Essentials of Diagnosis
• Acute varicella: fever, malaise with eruption of pruritic, centripetal,
papular rash, vesicular and pustular before crusting; lesions in all
stages at any given time; "drop on rose petal" is the first lesion
• Incubation period 14-21 days
• Bacterial infection, pneumonia, and encephalitis may complicate
• Reactivation varicella (herpes zoster): dermatomal distribution,
vesicular rash with pain often preceding eruption
• Differential Diagnosis
• Other viral infections
• Drug allergy
• Treatment
• Supportive measures with topical lotions and antihistamines;
antivirals (acyclovir, valacyclovir, famciclovir) for all adults with
varicella
• Immune globulin or antivirals for exposed susceptible immunosuppressed
or pregnant patients
• Acyclovir early for immunocompromised or pregnant patients,
severe disease (eg, pneumonitis, encephalitis), or ophthalmic
division of trigeminal nerve involvement with zoster
• Corticosteroids combined with antiviral agent with rapid taper
may diminish postherpetic neuralgia in older patients with zoster
• Pearl
Epidemics are morefrequent in winter and spring and in temperate climates.
Reference
Weller TH: Varicella: historical perspective and clinical overview. J Infect Dis
1996:174(Suppl 3):S306. [PMJD: 8896536]
Chapter 8 Infectious Diseases 203
Mumps (Epidemic Parotitis)
+
• Essentials of Diagnosis
• Painful, swollen salivary glands, usually parotid; may be unilateral
• Incubation period 12-24 days
• Orchitis or oophoritis, meningoencephalitis, or pancreatitis may
occur
• Cerebrospinal fluid shows lymphocytic pleocytosis in meningoencephalitis
with hypoglycorrhachia
• Diagnosis confirmed by isolation of virus in saliva or appearance
of antibodies after second week
• Differential Diagnosis
• Parotitis or enlarged parotids due to other causes (eg, bacteria,
sialolithiasis, cirrhosis, diabetes, starch ingestion, Sjogren's syndrome,
sarcoidosis, tumor)
• Aseptic meningitis, pancreatitis, or orchitis due to other causes
• Treatment
• Immunization is preventive
• Supportive care with surveillance for complications
• Pearl
Mumps is a treatable cause ofsterility, associated with high blood FSH
ana low testosterone levels.
Reference
McQuone Sf: Acute viral and bacterial infections of the salivary glands. Otolaryngol
Clin North Am 1999;32:793. [PMID: 10477787]
204 Essentials of Diagnosis & Treatment
Viral Encephalitis
+
• Essentials of Diagnosis
• Most common agents include enterovirus, Epstein-Barr virus,
and viruses of herpes simplex, measles, rubella, rubeola, varicella,
West Nile fever
• Fever, malaise, stiff neck, nausea, altered mentation
• Signs of upper motor neuron lesion: exaggerated deep tendon
reflexes, absent superficial reflexes, spastic paralysis
• Increased cerebrospinal fluid protein with lymphocytic pleocytosis,
occasional hypoglycorrhachia
• Isolation of virus from blood or cerebrospinal fluid; serology positive
in paired specimens 3-4 weeks apart
• Brain imaging shows temporal lobe abnormalities in herpetic
encephalitis
• Differential Diagnosis
• Other encephalitides (postvaccination, Reye' s syndrome, toxins)
• Lymphocytic choriomeningitis
• Primary or secondary neoplasm
• Bacterial meningitis or brain abscess
• Treatment
• Vigorous supportive measures with attention to elevated central
nervous system pressures
• Mannitol in selected patients
• Acyclovir for suspected herpes simplex encephalitis; other specific
antiviral therapy is under study
• Pearl
In patients with suspected encephalitis, acyclovir is given until herpes
is excluded.
Reference
Roos KL: Encephalitis. Neural Clin 1999;17:813. [PMID: 10517930]
Chapter 8 Infectious Diseases 205
Poliomyelitis
+
• Essentials of Diagnosis
• Enterovirus acquired via fecal-oral route; vast majority of symptomatic
cases are not neurologic
• Muscle weakness, malaise, headache, fever, nausea, abdominal
pain, sore throat
• Signs of lower motor neuron lesions: asymmetric, flaccid paralysis
with decreased deep tendon reflexes, muscle atrophy; may
include cranial nerve abnormalities (bulbar form)
• Cerebrospinal fluid lymphocytic pleocytosis with slightelevation
of protein
• Virus recovered from throat washings or stool
• Differential Diagnosis
• Other aseptic meningitides
• Postinfectious polyneuropathy (Guillain-Barre syndrome)
• Amyotrophic lateral sclerosis
• Myopathy
• Treatment
• Vaccination is preventive and has eliminated the disease in the
United States
Supportive care with particular attention to respiratory function,
skin care, and bowel and bladder function
• Pearl
Stiffneck after an enteric illness is a potential precursor ofneurologic
polio.
Reference
Melnick JL: Current status of poliovirus infections. Clin Microbial Rev
1996;9:293. [PMID: 8809461]
206 Essentials of Diagnosis & Treatment
Lymphocytic Choriomeningitis
• Essentials of Diagnosis
• History of exposure to mice or hamsters
• "Influenza-like" prodrome with fever, chills, headache, malaise,
and cough followed by headache, photophobia, or neck pain
• Kernig and Brudzinski signs positive
• Cerebrospinal fluid with lymphocytic pleocytosis and slight increase
in protein
• Serology for arenavirus positive 2 weeks after onset of symptoms;
virus recovered from blood and cerebrospinal fluid
• Illness usually lasts 1-2 weeks
+
• Differential Diagnosis
• Other aseptic meningitides
• Bacterial or granulomatous meningitis
• Treatment
• Supportive care
• Pearl
One of the few causes ofhypoglycorrhachia in a patient who appears
to he well.
Reference
Barton LL et al: Lymphocytic choriomeningitis virus: reemerging central nervous
system pathogen. Pediatrics 2000; 105:E35. [PM 10: 10699137]
Chapter 8 Infectious Diseases 207
+
Dengue (Breakbone Fever, Dandy Fever)
• Essentials of Diagnosis
• A viral (togavirus, f1avivirus) illness transmitted by the bite of the
Aedes mosquito
• Sudden onset of high fever, chills, severe myalgias, headache,
sore throat
• Biphasic fever curve with initial phase of 3-4 days, short remission,
and second phase of 1-2 days
• Rash is biphasic-first evanescent, followed by maculopapular,
scarlatiniform, morbilliform, or petechial changes during remission
or second phase of fever; first in the extremities and spreads
to torso
• Dengue hemorrhagic fever is a severe form in which gastrointestinal
hemorrhage is prominent and patients often present with
shock
• Differential Diagnosis
• Malaria
• Yellow fever
• Influenza
• Typhoid fever
• Borreliosis
• Other viral exanthems
• Treatment
• Supportive care
• Vaccine has been developed but not commercially available
• Pearl
Dengue should always be considered in the febrile returned traveler
with presumed influenza.
Reference
Rigau-Perez JG et al: Dengue and dengue haemorrhagic fever. Lancet
1998;352:971. [PMlD: 9752834]
208 Essentials of Diagnosis & Treatment
Colorado Tick Fever
• Essentials of Diagnosis
• A self-limited acute viral (coltivirus) infection transmitted by
Dermacentor andersoni tick bites
• Onset 3-6 days following bite
• Abrupt onset of fever, chills, myalgia, headache, photophobia
• Occasional faint rash
• Second phase of fever after remission of 2-3 days common
• Imbedded ticks, especially in children's scalps, may cause paresis
• Differential Diagnosis
• Borrelliosis
• Influenza
• Adult Still's disease
• Other viral exanthems
• Guillain-Barre syndrome (if paralysis present)
• Treatment
• Supportive for uncomplicated cases
• With paresis, removal of tick results in prompt resolution of
symptoms
• Pearl
A tick-borne disease of the western mountains not associated with
paralysis.
Reference
Attoui H: Serologic and molecular diagnosis of Colorado tick fever viral infections.
Am J Trop Med Hyg 199859:763. [PMlD: 9840594]
Chapter 8 Infectious Diseases 209
Rabies
• Essentials of Diagnosis
• A rhabdovirus encephalitis transmitted by infected saliva
• History of animal bite (bats, bears, skunks, foxes, raccoons; dogs
and cats in developing countTies)
• Paresthesias, hydrophobia, rage alternating with calm
• Convulsions, paralysis, thick tenacious saliva and muscle spasms
• Differential Diagnosis
• Tetanus
• Encephalitis due to other causes
• Treatment
• Active immunization of household pets and persons at risk (eg,
veterinarians)
• Thorough, repeated washing of bite and scratch wounds
• Postexposure immunization, both passive and active
• Observation of healthy biting animals, examination of brains of
sick or dead biting animals
• Treatment is supportive only; disease is almost uniformly fatal
• Pearl
Bats are the most common vector for rabies in the United States, and
even absent history of a bite, children exposed to bats indoors should
be immunized.
Reference
Plotkin SA: Rabies. Clin Infect Dis 1998;59:763. [PMID: 10619725]
+
210 Essentials of Diagnosis & Treatment
Influenza
• Essentials of Diagnosis
• Caused by an orthomyxovirus transmitted via the respiratory route
• Abrupt onset offever, headache, chills, malaise, dry cough, coryza,
and myalgias; constitutional signs out of proportion to catarrhal
symptoms
• Epidemic outbreaks in fall or winter, with short incubation period
• Virus isolated from throat washings; serologic tests positive after
second week of illness
• Complications include bacterial sinusitis, otitis media, and pneumonia
• Myalgias occur early in course, rhabdomyolysis late
• Differential Diagnosis
• Other viral syndromes
• Primary bacterial pneumonia
• Meningitis
• Dengue in returned travelers
• Rhabdomyolysis of other cause
• Treatment
• Yearly active immunization of persons at high risk (eg, chronic
respiratory disease, pregnant women, cardiac disease, health care
workers, immunosuppressed); also for all over 50
• Chemoprophylaxis for epidemic influenza A effective with amantadine;
zanamivir and oseltamivir effective against influenza A
and B
Antivirals reduce duration of symptoms and infectivity if given
within 48 hours
• Avoid salicylates in children because of association with Reye's
syndrome
• Pearl
Complicating staphylococcal pnewnonia is the most common cause of
death in epidemics.
Reference
Stamboulian D: Influenza. Infect Dis Clin North Am 2000;14:141. [PMID:
10738677]
Chapter 8 Infectious Diseases 211
+
Infectious Mononucleosis
(Epstein-Barr Virus Infection)
• Essentials of Diagnosis
• An acute viral illness due to EBV, usually occurring up to age 35
but any age possible
• Transmitted by saliva; incubation period is 5-15 days or longer
• Fever, severe sore throat, striking malaise, lymphadenopathy
• Maculopapular rash, splenomegaly common
• Leukocytosis and lymphocytosis with atypical large lymphocytes
by smear; positive heterophil agglutination test (Monospot) by
fourth week of illness; false-positive rapid plasma reagin test
(RPR) in 10%
• Clinical picture much less typical in older patients
• Complications include splenic rupture, hepatitis, myocarditis,
thrombocytopenia, and encephalitis
• Differential Diagnosis
• Other causes of pharyngitis
• Other causes of hepatitis
• Toxoplasmosis
• Rubella
• Acute HIV, CMV, or rubella infections
• Acute leukemia or lymphoma
• Kawasaki syndrome
• Hypersensitivity reaction due to carbamazepine
• Treatment
• Supportive care only; fever usually disappears in 10 days, lymphadenopathy
and splenomegaly in 4 weeks
• Ampicillin apt to cause rash
• Avoid vigorous abdominal activity or exercise
• Pearl
Mononucleosis is the most common cause of the otherwise rare anti-i
hemolytic anemia.
Reference
Cohen J1: Epstein-Barr virus infection. N Engl J Med 2000;343:481. [PMlD:
10944566]
212 Essentials of Diagnosis & Treatment
RICKETTSIAL INFEC1'IONS
Rocky Mountain Spotted Fever (Rickettsia ricketlsiij
• Essentials of Diagnosis
• Exposure to tick bite in endemic area
• Influenza! prodrome followed by chills, fever, severe headache,
myaIgias, occasionally delirium and coma
• Red macular rash with onset between second and sixth days of
fever; first on extremities, then centrally, may become petechia!
or purpuric
• Leukocytosis, proteinuria, hematuria
• Serologic tests positive by second week of illness, but diagnosis
may be made earlier by skin biopsy with immunologic staining
+
• Differential Diagnosis
• Meningococcemia
• Endocarditis
• Gonococcemia
• Ehrlichiosis
• Measles
• Treatment
• Tetracyclines or chloramphenicol
• Vaccine in development
• Pearl
Despite the name, Rocky Mountain spotted fever is for more common
in the southeastern United States.
Reference
Thorner AR et al: Rocky Mountain spotted fever. Clin Infect Dis 1998;27: I353.
[PMID: 9868640]
Chapter 8 Infectious Diseases 213
QFever (Coxiella burnettii)
+
• Essentials of Diagnosis
• Infection following exposure to sheep, goats, cattle, or fowl
• Acute or chronic febrile illness with severe headache, cough, and
abdominal discomfort
• Pulnnonary infiltrates by chest x-ray; leukopenia
• Serologic confirmation by third to fourth weeks of illness
• Granulomatous hepatitis and culture-negative endocarditis in
occasional cases
• Differential Diagnosis
• Atypical pneumonia
• Granulomatous hepatitis due to other cause
• Brucellosis
• Other causes of culture-negative endocarditis
• Treatment
• Tetracyclines suppressive but not always curative, especially
with endocarditis; surgery may be necessary
• Vaccine being developed
• Pearl
Some recent outbreaks are laboratory-acquired where sheep are used
in cardiovascular research.
Reference
Maurin M: Q fever. Clin Microbial Rev 1999; 12:518. [PMID: 1051590 I]
214 Essentials of Diagnosis &Treatment
BACTERIAL INFEC'nONS
Streptococcal Pharyngitis
• Essentials of Diagnosis
• Abrupt onset of sore throat, fever, malaise, nausea, headache
• Pharynx erythematous and edematous with exudate; cervical
adenopathy
• Strawberry tongue
• Throat culture or rapid antigen detection confirmatory
• If erythrotoxin (scarlet fever) is produced, scarlatiniform rash red
and papular with petechiae and fine desquamation; prominent in
axilla, groin, behind knees
• Glomerulonephritis, rheumatic fever may complicate
+
• Differential Diagnosis
• Viral pharyngitis
• Mononucleosis
• Diphtheria
• With rash: meningococcemia, toxic shock syndrome, drug reaction,
viral exanthem
• Treatment
• For two or more clinical criteria (cervical adenopathy, fever, exudate,
and absence of rhinorrhea): empiric penicillin
• If equivocal, await culture or antigen confirmation
• If history of rheumatic fever, continuous antibiotic prophylaxis
for 5 years
• Pearl
Despite the clinical severity of pharyngeal diphtheria. fever is higher
in strep throat.
Reference
Bisno AL: Acute pharyngitis. N Engl J Med 2001 ;344:205. [PMID: 11172144]
+
Chapter 8 Infectious Diseases 215
Streptococcal Skin Infection
• Essentials of Diagnosis
• Erysipelas: rapidly spreading cutaneous erythema and edema
with sharp borders
• Impetigo: rapidJy spreading erythema with vesicular or denuded
areas and salmon-colored crust
• Culture of wound or blood grows group A beta hemolytic streptococci
• Complication: glomerulonephritis
• Differential Diagnosis
• Other causes of infectious cellulitis (eg, staphylococcal, E coli)
• Toxic shock syndrome
• Beriberi (in setting of thiamin deficiency)
• Treatment
• Penicillin for culture-proved streptococcal infection
• Staphylococcal coverage (dicloxacillin) for empiric therapy or
uncertain diagnosis
• Pearl
Group Acutaneous infections can result in glomerulonephritis but not
rheumatic fever.
Reference
Bisno AL et al: Streptococcal infections of skin and soft tissues. N Engl J Med
1996;334:240. [PMlD: 8532002]
+
216 Essentials of Diagnosis & Treatment
Pneumococcal Infections
• Essentials of Diagnosis
• Pneumonia characterized by initial chill, severe pleuritis, fever
without diurnal variation; signs of consolidation and lobar infiltrate
on x-ray ensue rapidly
• Leukocytosis, hyperbilirubinemia
• Gram-positive diplococci on Gram-stained smear of sputum;
lancet-shaped only on stained culture colonies
• Meningitis: rapid onset of fever, altered mental status and headache;
cerebrospinal fluid polymorphonuclear leukocytosis with
elevated protein and decreased glucose; Gram-stained smear of
fluid positive in 90% of cases
Endocarditis, empyema, pericarditis, and arthritis may also complicate,
with empyema most common
• Predisposition to bacteremia in children under 24 months of age
or in asplenic or immunocompromised adults (eg, AIDS, elderly)
• Differential Diagnosis
• Pneumonia, meningitis of other cause
• Pulmonary embolism
• Myocardial infarction
• Acute exacerbation of chronic bronchitis
• Acute bronchitis
• Gram-negative septicemia
• Treatment
• Blood culture prior to antibiotics
• Third-generation cephalosporin for severe disease; add empiric
vancomycin for meningitis pending culture results
• Adults over 50 with any serious medical illness, patients with
sickle cell disease, and asplenic patients should receive pneumococcal
vaccine
Penicillin unreliahle pending results of susceptihility testing
• Pearl
Rigors after the first day of infection in a patient with pneumonia suggest
a different etiology or an extrapulmonary complication.
Reference
Harwell 11: The drug-resistant pneumococcus: clinical relevance, therapy, and
prevention. Chest 2000;117:530. [PMlD: 10669700]
+
Chapter 8 Infectious Diseases 217
Staphylococcal Soft Tissue or Skin Infections
• Essentials of Diagnosis
• Painful, pruritic erythematous rash with golden crusts or discharge
• Folliculitis, furunculosis, carbuncle, abscess, and cellulitis all seen
• Culture of wound or abscess is diagnostic; Gram-stained smear
positive for large gram-positive cocci (Staphylococcus aureus) in
clusters
• Differential Diagnosis
• Streptococcal skin infections
• Treatment
• Penicillinase-resistant penicillin or cephalosporin; erythromycin
may also be effective in some cases
• Drainage of abscess
• Persistence of blood culture positivity suggests endocarditis or
osteomyelitis
• Pearl
Gram stain of material infected with staphylococci shows marked
avidity ofthe organismsfor the stain; they also thrive intracellularlyin
contrast to pneumococci.
Reference
Thestrup-Pedersen K: Bacteria and the skin: clinical practice and therapy update.
8r J Dermatol 1998; 139(Suppl)53: I. [PMID: 9990405]
+
218 Essentials of Diagnosis & Treatment
Staphylococcus aureus-Associated Toxic
Shock Syndrome
• Essentials of Diagnosis
• Abrupt onset of fever, vomiting, diarrhea, sore throat, headache,
myalgia
• Toxic appearance, with tachycardia and hypotension
• Diffuse maculopapular erythematous rash with desquamation on
the palms and soles; nonpurulent conjunctivitis
• Association with tampon use; culture of nasopharynx, vagina,
rectum, and wounds may yield staphylococci, but blood cultures
usually negative
• Usually caused by toxic shock syndrome toxin-I (TSST-l)
• Differential Diagnosis
• Streptococcal infection, particularly scarlet fever
• Gram-negative sepsis
• Rickettsial disease, especially Rocky Mountain spotted fever
• Treatment
• Aggressive supportive care (eg, fluids, vasopressor medication,
monitoring)
• Antistaphylococcal antibiotics to eliminate source
• Pearl
Consider chronic staphylococcal osteomyelitis as a potential cause of
toxic shock syndrome.
Reference
Bannan J et al: Structure and function of streptococcal and staphylococcal superantigens
in septic shock. Infect Dis Clinics North Am 1999;13:387. [PMlD:
10340173]
Chapter 8 InfectioLis Diseases 219
Clostridial Myonecrosis (Gas Gangrene)
• Essentials of Diagnosis
• Sudden onset of pain, swelling in an area of wound contamination
• Severe systemic toxicity and rapid progression of involved tissue
• Brown or blood-tinged watery exudate with surrounding skin discoloration
• Gas in tissue by palpated or auscultated crepitus or x-ray
• Clostridium peifringens in anaerobic culture or smear of exudate
is the classic-but not the only-cause
• Differential Diagnosis
• Other gas-forming infections (mixed aerobic and anaerobic enteric
organisms)
• Cellulitis due to staphylococcal or streptococcal infection
• Treatment
• Immediate surgical debridement and exposure of infected areas
• Hyperbaric oxygen of uncertain benefit
• Intravenous penicillin with clindamycin
• Tetanus prophylaxis
• Pearl
In a patient severely symptomatic and extremely toxic with the clinical
picture noted, a relatively low-grade fever is virtually diagnostic ofgas
gangrene.
Reference
Chapnick EK: NeclDtizing soft-tissue infections. Infect Dis Clinics NOl1h Am
1996;IO:835.[PMID: 8958171])
+
220 Essentials of Diagnosis &Treatment
Tetanus (Clostridium tetani)
• Essentials of Diagnosis
• History of nondebrided wound or contamination mayor may not
be obtained
• Jaw stiffness followed by spasms (trismus)
• Stiffness of neck or other muscles, dysphagia, irritability, hyperreflexia;
late, painful convulsions precipitated by minimal stimuli;
fever is low-grade
• Differential Diagnosis
• Infectious meningitis
• Rabies
• Strychnine poisoning
• Malignant neuroleptic syndrome
• Hypocalcemia
• Treatment
• Active immunization preventive
• Passive immunization with tetanus immune globulin and concurrent
active immunization for all suspected cases
• Chlorpromazine or diazepam for spasms or convulsions, with additional
sedation by barbiturates as necessary
• Vigorous supportive care with particular attention to airway and
laryngospasm
• Penicillin
• Pearl
Tetanus should be high on the list in "skin-popping" illicit drug users
with increased muscle tone.
Reference
Ernst ME et al: Tetanus: pathophysiology and management. Ann Pharmacother
1997;31:1507. [PMlD: 9416389]
+
Chapter 8 Infectious Diseases 221
Botulism (Clostridium botulinum)
• Essentials of Diagnosis
• Sudden onset of cranial nerve paralysis, diplopia, dry mouth, dysphagia,
dysphonia, and progressive muscle weakness
• Fixed and dilated pupils in 50%
• In infants: irritability, weakness, and hypotonicity
• History of recent ingestion of home-canned, smoked, or vacuumpacked
foods
• Demonstration of toxin in serum or food
• Differential Diagnosis
• Bulbar poliomyelitis
• Myasthenia gravis
• Posterior cerebral circulation ischemia
• Tick paralysis
• Guillain-Barre syndrome or variant
• Inorganic phosphorus poisoning
• Treatment
• Removal of unabsorbed toxin from gut
• Specific antitoxin (CDC Poison Control Hotline 800-292-6678)
• Vigilant support, including attention to respiratory function
• Penicillin
• Pearl
In intravenous drug users with cranial nerve findings, this picture is
classic for wound botulism caused by black tar heroin.
Reference
Shapiro RL et al: Botulism in the United States: a clinical and epidemiologic
review. Ann Intern Med 1998; 129:221. [PMID: 9696731]
222 Essentials of Diagnosis & Treatment
Anthrax (Bacillus anthracis)
• Essentials of Diagnosis
• History of industrial or agricultural exposure (farmer, veterinarian,
tannery or wool worker); a potential agent in biological warfare
• Persistent necrotic uleer on exposed surface
• Regional adenopathy, fever, malaise, headache, nausea and vomiting
• Inhalation of spores causes severe tracheobronchitis and pneumonia
with dyspnea and cough
• Hematologic spread with profound toxic and cardiovascular collapse
may complicate either cutaneous or pulmonary fonn
• Confirmation of diagnosis by culture or specific fluorescent antibody
test, but clinical picture highly suggestive
• Differential Diagnosis
• Skin lesions: staphylococcal or streptococcal infection
• Pulmonary disease: tuberculosis, fungal infection, sarcoidosis,
lymphoma with mediastinal adenopathy, plague
• Treatment
• Therapy for post exposure prophylaxis is oral doxycycline or oral
ciprofloxacin
• Optimal therapy for confirmed disease due to a susceptible strain
is oral amoxacillin or oral doxycycline for 60 days
• Mortality rate is high despite proper therapy, especially in pulmonary
disease
• Pearl
A rare infectious disease in which the patient "dies sterile "---all organisms
are eliminated, but the toxicity is lethal.
Reference
Swartz MN: Recognition and management of anthrax-an update. N Engl J Med
2001; 345: 1626. [PMID: 11757510]
Chapter 8 Infectious Diseases 223
Diphtheria (Corynebacterium diphtheriae)
• Essentials of Diagnosis
• An acute infection spread by respiratory secretions
• Sore throat, rhinorrhea, hoarseness, malaise, relatively unimpressive
fever (usually < 37.8 0c)
• Tenacious gray membrane at portal of entry
• Toxin-induced myocarditis and neuropathy may complicate, due
to an exotoxin
• Smear and culture confirm diagnosis
• Differential Diagnosis
• Other causes of pharyngitis (streptococcal, infectious mononucleosis,
adenovirus)
• Necrotizing gingivostomatitis
• Candidiasis
• Myocarditis from other causes
• Myasthenia gravis
• Botulism
• Treatment
• Active immunization (usually as DTP) is preventive
• Diphtheria antitoxin
• Penicillin or erythromycin
• Corticosteroids in selected patients with severe laryngeal involvement,
myocarditis, or neuropathy
• Exposures of susceptible individuals call for booster toxoid, active
immunization, antibiotics, and daily throat inspections
• Pearl
Hypesthetic shallow skin ulcers in homeless patients suggest the diagnosis
ofcutaneous diphtheria.
Reference
Galazka A: The changing epidemiology of diphtheria in the vaccine era. J Infect
Dis 2000;181(SuppI1):S2. [pMID: 10657184]
+
224 Essentials of Diagnosis & Treatment
Pertussis (Bordetella pertussis)
• Essentials of Diagnosis
• An acute infection of the respiratory tract spread by respiratory
droplets
• History of declined DTP vaccination
• Two-week prodromal catarrhal stage of malaise, cough, coryza,
and anorexia; seen predominantly in infants under age 2
• Paroxysmal cough ending in high-pitched inspiratory "whoop"
(whooping cough)
• Absolute lymphocytosis with extremely high white counts possible
• Culture confirms diagnosis
• Differential Diagnosis
• Yiral pneumonia
• Foreign body aspiration
• Acute bronchitis
• Acute leukemia (when leukocytosis marked)
• Treatment
• Active immunization preventive (as part of DTP)
• Erythromycin with immune gJobulinin selected patients
• Treat secondary pneumonia and other complications
• Pearl
The cause ofthe highest benign white counts in clinical medicine.
Reference
Orenstein WA: Pertussis in adults: epidemiology, signs, symptoms, and implications
for vaccination. Clin Infect Dis 1999;28(Suppl 2):S147. IPM1D:
10447034]
Chapter 8 Infectious Diseases 225
+
Meningococcal Meningitis (Neisseria meningitidis)
• Essentials of Diagnosis
• Fever, headache, vomiting, confusion, delirium, or seizures; typically
epidemic in young adults; onset may be astonishingly abrupt
• Petechial or ecchymotic rash of skin and mucous membranes
• May have positive Kernig and Brudzinski signs
• Purulent spinal fluid with gram-negati ve intracellular and extracellular
cocci by Gram-stained smear
• Culture of cerebrospinal fluid, blood, or petechial aspirate confirms
diagnosis
• Disseminated intravascular coagulation and shock may complicate
• Differential Diagnosis
• Meningitis due to other causes
• Petechial rash due to rickettsial, viral, or other bacterial infection
• Idiopathic thrombocytopenic purpura
• Treatment
• Active immunization available for selected susceptible groups
(military recruits, college dormitory residents)
• Penicillin, ceftriaxone, or chloramphenicol
• Mannitol and corticosteroids for elevated intracranial pressure
• Ciprofloxacin (single dose) or rifampin (2 days) therapy for intimate
exposures
• Pearl
The most common bacterial meningitis in which organisms are not seen
on cerebrospinaljluid Gram stain (50% ofcases).
Reference
Salzman MB et al: Meningococcemia. Infect Dis Clin North Am 1996;
10:709. [pMID: 8958165]
226 Essentials of Diagnosis & Treatment
Legionnaire's Disease
+
• Essentials of Diagnosis
• Caused by Legionella pneumophila and a common cause of
community-acquired pneumonia in some areas
• Seen in patients who are immunocompromised or have chronic
lung disease
• Malaise, dry cough, fever, headache, pleuritic chest pain, toxic
appearance, purulent sputum
• Chest x-ray with patchy infiltrates often unimpressive early; subsequent
development of effusion or multiple lobar involvement
common
• Purulent sputum without organisms seen by Gram stain; diagnosis
confirmed by culture or special silver stains or direct fluorescent
antibodies, urinary antigen
• Differential Diagnosis
• Other infectious pneumonias
• Pulmonary embolism
• Pleurodynia
• Myocardial infarction
• Treatment
• Erythromycin with rifampin added in severe disease or immunocompromised
patients
• Newer macrolides and quinolones are also effective (but expensive)
alternatives
• Pearl
The early assertion that hyponatremia and gastrointestinal symptoms
are diagnostic is erroneous-many atypical pneumonias have the same
problem.
Reference
Ereiman RF et al: Legionnaires' disease: clinical, epidemiological, and public
health perspectives. Semin Respir Infect 1998;13:84. [pMID: 9643385]
Chapter 8 Infectious Diseases 227
+
Enteric Fever (Typhoid Fever)
• Essentials of Diagnosis
• Caused by several salmonella species; in "typhoid fever," serotype
Salmonella typhi is causative and accompanied by bacteremia
• Transmitted by contaminated food or drink; incubation period is
5-14 days
• Gradual onset of malaise, headache, sore throat, cough, followed
by diarrhea or, with S typhi, constipation; stepladder rise offever
to maximum of 40°C over 7-10 days, then slow return to normal
with little diurnal variation
• Rose spots, relative bradycardia, splenomegaly, abdominal distention
and tenderness
• Leukopenia; blood, stool, and urine cultures positive for S typhi
(group D) or other salmonellae
• Differential Diagnosis
• Brucellosis
• Tuberculosis
• Infectious endocarditis
• Qfever and other rickettsial infections
• Yersiniosis
• Hepatitis
• Lymphoma
• Adult Still's disease
• Treatment
• Active immunization helpful during epidemics for travelers to
endemic areas or for household contacts of persons with the
disease
• Ciproftoxacin or second-generation cephalosporin pending susceptibility
results
• Cholecystectomy may be necessary for relapsed cases
• Complications in one-third of untreated patients include intestinal
hemorrhage or perforation, cholecystitis, nephritis, and meningitis
• Pearl
The development of tachycardia and leukocytosis in a patient with
typhoidfever suggests ileal perforation until proved otherwise.
Reference
Magill AJ: Fever in the returned traveler. Infect Dis Clin North Am 1998; 12:445.
[PMTD: 9658253]
228 Essentials of Diagnosis & Treatment
Salmonella Gastroenteritis
(Various Salmonella Species)
• Essentials of Diagnosis
• The most common form of salmonellosis
• Nausea, headache, meningismus, fever, high-volume diarrhea,
usually without blood, and abdominal pain 8-48 hours after ingestion
of contaminated food or liquid
• Positive fecal leukocytes
• Culture of organism from stool; bacteremia less common
• Differential Diagnosis
• Viral gastroenteritis, especially enterovirus
• Dysenteric illness (shigella, campylobacter, amebic)
• Enterotoxigenic E coli infection
• Inflammatory bowel disease
• Treatment
• Rehydration and potassium repletion
• Antibiotics (ciprofloxacin or ceftriaxone) essential in those with
sickle cell anemia or immunosuppression
• In others, antimicrobials reduce symptoms by 1-2 days
• Pearl
All patients continuously bacteremic with salmonella should be suspected
ofhaving a mycotic aortic aneurysm.
Reference
Slutsker Let al: Foodbome diseases. Emerging pathogens and trends. Infect Dis
Clin North Am 1998; 12: 199. [PMID: 9494839]
Chapter 8 Infectious Diseases 229
Bacillary Dysentery (Shigellosis)
• Essentials of Diagnosis
• Fever, malaise, toxicity, diarrhea (typically bloody), cramping
• Positive fecal leukocytes; organism isolated in stool; in immunosuppressed
patients, blood culture often positive-not so in others
• Differential Diagnosis
• Campylobacter and salmonella infection
• Amebiasis
• Ulcerative colitis
• Viral gastroenteritis
• Food poisoning
• Treatment
• Supportive care
• Antibiotics determined based on sensitivities of local shigella
species; trimethoprim-sulfamethoxazole and ciproftoxacin are
the usual drugs of choice
• Pearl
The first organism associated with reactive arthritis.
Reference
Edwards BH: Salmonella and Shigella species. Clin Lab Med 1999;19:469.
[pMID: 10549421]
230 Essentials of Diagnosis &Treatment
Campylobacter Enteritis (Campy/obaeter jejuni)
• Essentials of Diagnosis
• Outbreaks associated with consumption of raw milk
• Fever, vomiting, abdominal pain, bloody diarrhea
• Fecal leukocytes present; presumptive diagnosis by darkfield or
phase contrast microscopy of stool wet mount
• Definitive diagnosis by stool culture
+
• Differential Diagnosis
• Shigellosis
• Salmonellosis
• Viral gastroenteritis
• Amebic dysentery
• Food poisoning
• Ulcerative colitis
• Treatment
• Erythromycin orciproftoxacin will shorten the duration of illness
by approximately 1 day
• Disease is self-limited but can be severe
• Pearl
The most commonly isolated pathogen in dysentery.
Reference
Fields PI et al: Campylobacterjejuni. Clin Lab Med 1999;19:489. [PMID:
10549422]
Chapter 8 Infectious Diseases 231
Cholera (Vibrio choleraej
+
• Essentials of Diagnosis
• Acute diarrheal illness leading to profound hypovolemia and
death if not addressed promptly
• Occurs in epidemics under conditions of crowding and famine;
acquired via ingestion of contaminated food or water
• Sudden onset of frequent, high-volume diarrhea
• Liquid ("rice water") stool is gray, turbid
• Rapid development of hypotension, marked dehydration, acidosis,
and hypokalemia
• History of travel to endemic area or contact with infected person
• Positive stool culture confirmatory; serologic testing useful in
first to second weeks
• Differential Diagnosis
• Other small intestinal diarrheal illness (eg, salmonellosis, enterotoxigenic
E coli)
• Viral gastroenteritis
• VIP-producing pancreatic tumor (pancreatic cholera)
• Treatment
• Vaccination preventive for travelers to endemic areas but is rarely
indicated (www.cdc.gov/travel/)
• Rapid replacement of fluid and electrolytes, especially potassium
• Cola beverages inhibit cAMP, reduce diarrhea, in areas where
standard volume repletion is unavailable
• Tetracycline and many other antibiotics may shorten duration of
vibrio excretion
• Pearl
In cholera, markedly elevated hematocrits from severe dehydration
may lead to hyperviscosity ofthe circulation.
Reference
Kaper JB et al: Cholera. Clin Microbial Rev 1995;8:48. [PM1D: 7704895]
232 Essentials of Diagnosis &Treatment
Brucellosis (Brucella Species)
• Essentials of Diagnosis
• Invariable history of animal exposure (veterinarian, slaughterhouse)
or ingestion of unpasteurized milk or cheese
• Vectors are catde, hogs, and goats
• Insidious onset of fever, diaphoresis, anorexia, fatigue, headache,
back pain
• Cervical and axillary lymphadenopathy, hepatosplenomegaly
• Lymphocytosis with normal total white cell count; positive blood,
cerebrospinal fluid, or bone marrow culture after days to weeks;
serologic tests positive in second week of illness
• Osteomyelitis, epididymitis, meningitis, and endocarditis may
complicate
• Differential Diagnosis
• Lymphoma
• Infective endocarditis
• Tuberculosis
• Qfever
• Typhoid fever
• Tularemia
• Malaria
• Other causes of osteomyelitis
• Treatment
• Rifampin and doxycycline required for 21days
• Pearl
In clinically typical brucellosis, dilution ofpreviously negative serum
sample is ordered to exclude a prozone effect; drastically high titers are
falsely negative unless diluted.
Reference
Corbel MJ: Brucellosis: an overview. Emerg Infect Dis 1997;3:213. [PMID:
9204307]
Chapter 8 Infectious Diseases 233
+
Tularemia (Francisella lularensisj
• Essentials of Diagnosis
• History of contact with rabbits, other rodents, and biting arthropods
(eg, ticks) in endemic areas; incubation period 2-10 days
• Fever, headache, nausea begin suddenly
• Papule progressing to ulcer at site of inoculation; the conjunctiva
may be the site in occasional patients
• Prominent, tender regional lymphadenopathy, splenomegaly
• Diagnosis confirmed by culture of ulcerated lesion, lymph node
aspirate, or blood; serologic confirmation positive after second
week of illness
• Though primarily cutaneous, ocular, glandular, or typhoidal; only
the very rare pneumonic form is transmissible between humans
• Differential Diagnosis
• Cat-scratch disease
• Infectious mononucleosis
• Plague
• Typhoid fever
• Lymphoma
• Various rickettsial infections
• Meningococcemia
• Treatment
• Combination antibiotics required; streptomycin and tetracycline
are usually used
• Pearl
Although namedfor the index case in Tulare County in California, the
most prominent epidemic was on Martha's Vineyard in Massachusetts;
it is rarely encountered in Tulare County.
Reference
Gill Vet al: Tularemia pneumonia. Semin Respir Infect 1997;12:61. [PMID:
9097380]
+
234 Essentials of Diagnosis & Treatment
Plague (Yersinia pestis)
• Essentials of Diagnosis
• History of exposure to rodents in endemic area of southwestern
United States; by bites of fleas or contact with infected rodents;
human-to-human transmission with pneumonic plague only
• Sudden onset of high fever, severe malaise, myalgias; stunning
systemic toxicity
• Regional lymphangitis and lymphadenitis with suppuration of
nodes
• Bacteremia, pneumonitis, or meningitis complicate
• Positive smear and culture from aspirate or blood; striking leukopenia
with marked left shift
• Differential Diagnosis
• Tularemia
• Lymphadenitis with bacterial disease of extremity
• Lymphogranuloma venereum
• Other bacterial pneumonia or meningitis
• Typhoid fever
• Yarious rickettsial diseases
• Treatment
• Combination antibiotics required (eg, streptomycin plus tetracycline)
• Tetracycline prophylaxis for persons exposed to patients with
pneumonic plague
• Strict isolation of pneumonic disease patients
• Pearl
Plague should be treated empirically in any case ofmeningitis encountered
in the arid southwestern United States.
Reference
Titball RW et al: Plague. Br Med Bull 1998,54:625. [PMID: 10326289] (Dl:
99258139)
Chapter 8 Infectious Diseases 235
+
Gonorrhea (Neisseria gonorrhoeaej
• Essentials of Diagnosis
• A common communicable venereal disease; incubation period is
2-8 days
• Purulent profuse urethral discharge (men); vaginal discharge rare
(women); may be asymptomatic in both sexes
• Disseminated disease causes intermittent fever, skin lesions (few
in number and peripherally located), tenosynovitis in numerous
joints, and usually monarticular arthritis involving the knee, ankle,
or wrist
• Conjunctivitis, pharyngitis, proctitis, endocarditis, meningitis also
occur
• Gram-negative intracellular diplococci on urethral smear or culture
from cervix, rectum, or pharynx; molecular testing of first 10 mL
of urine superior to cervical or urethral cultures
• Synovial fluid cultures seldom positive
• Differential Diagnosis
• Cervicitis, vaginitis, or urethritis due to other causes
• Other causes of pelvic inflammatory disease
• Reactive arthritis
• Meningococcemia
• Treatment
• Rapid plasma reagin (RPR) obtained in all, HIV in selected cases
• Ceftriaxone intramuscularly for suspected cases; treat all sexual
partners
• Oral antibiotics for concurrent chlamydial infection also recommended
• Intravenous antibiotics required for salpingitis, prostatitis, arthritis,
or endocarditis
• Pearl
Gonococcal endocarditis is one of medicine's few causes of a biquotidianfever
spike.
Reference
Cohen MS et al: Human experimentation with Neisseria gonorrhoeae: progress
and goals. J Infect Dis 1999; 179(Suppl 2):S375. [PMID: 10081510]
236 Essentials of Diagnosis & Treatment
Chancroid (Haemophilus ducreyi)
• Essentials of Diagnosis
• A sexually transmitted disease with an incubation period of
3-5 days
• Painful, tender genital ulcer
• Inguinal adenitis with erythema or ftuctuance and multiple genital
ulcers often develop
• Balanitis, phimosis frequent complications
• Women have no external signs of infection
+
• Differential Diagnosis
• Beht;et's syndrome
• Syphilis
• Pyogenic infection of lower extremity with regional lymphadenitis
• Genital ulcers of other cause
• Treatment
• Appropriate antibiotic (azithromycin, ceftriaxone, erythromycin,
or ciproftoxacin)
• Rapid plasma reagin (RPR) for all, HIV when appropriate
• Pearl
Tender inguinal lymphadenopathy in overweight patients may not be
nodes; an incarceratedfemoral hernia may be the answer.
Reference
Eichmann A: Chancroid. Curr Probl Dermatol 1996;24:20. [PM] D: 8743249]
Chapter 8 Infectious Diseases 237
+
Granuloma Inguinale
(Calymmatobacterium granulomatis)
• Essentials of Diagnosis
• A chronic relapsing granulomatous anogenital infection; incubation
period is 1-12 weeks
• Ulcerative lesions on the skin or mucous membranes of the genitalia
or perianal area
• Donovan bodies revealed by Wright's or Giemsa's stain of ulcer
scrapings
• Differential Diagnosis
• Venereal ulcers of other cause
• Syphilis
• Herpes simplex
• Reactive arthritis
• Beht,:et's disease
• Treatment
• Appropriate antibiotic (erythromycin or tetracycline) for at least
21 days
• Surveillance and counseling for other STDs (eg, syphilis, gonorrhea,
mV)
• Pearl
The most indolent ofthe major venereal diseases.
Reference
Hart G: Donovanosis. Clin Infect Dis 1997;25:24. [pMID: 9243028]
+
238 Essentials of Diagnosis &Treatment
Cat-Scratch Disease (Bartonella hense/ae)
• Essentials of Diagnosis
• History of cat scratch or contact with cats; may be forgotten by
patient
• Primary lesion (papule, pustule, conjunctivitis) at site of inoculation
in one-third of cases
• One to 3 weeks after scratch, fever, malaise, and headache accompanied
by regional lymphadenopathy
• Sterile pus from node aspirate
• Biopsy consistent with cat-scratch disease with a necrotizing
lymphadenitis; positive skin test; positive serology for bacteria
• Bacillary angiomatosis and peliosis hepatis in immunosuppressed
patients
• Differential Diagnosis
• Lymphadenitis due to other bacterial infections
• Lymphoma
• Tuberculosis
• Toxoplasmosis
• Kikuchi's disease
• Treatment
• Nonspecific; exclusion of similar diseases most important
• Isoniazid, rifampin, or erythromycin in immunocompromised
patients
• Pearl
In a patient with isolated but bilateral axillary adenopathy and fever,
go back and take a pet history: this is a rare distribution for lymphoma.
Reference
Spach DH et al: Bartonella-associated infections. Infect Dis Clin North Am
1998; 12: J 37. [PMID: 9494835]
Chapter 8 Infectious Diseases 239
Actinomycosis
+
• Essentials of Diagnosis
• Due to anaerobic gram-positive rod (actinomyces species) normally
part of the mouth flora; becomes pathogenic when introduced
into traumatized tissue
• Chronic suppurative lesion of the skin (cervicofacial in 60%)
with sinus tract formation; thoracic or abdominal abscesses seen;
pelvic disease associated with intrauterine devices
• Accelerated sedimentation rate; anemia, thrombocytosis
• Isolation of actinomyces species or suI fur granule from pus by
anaerobic culture
• Sulfur granules show gram-positive hyphae on smear
• Differential Diagnosis
• Lung cancer
• Other causes of cervical adenitis
• Scrofula
• Nocardiosis
• Crohn' s disease
• Pelvic inflammatory disease of other cause
• Treatment
• Long-term penicillin
Surgical drainage necessary in selected cases
• Pearl
Poor dental hygiene in the face ofthe clinical scenario noted obligates
consideration ofactinomycosis.
Reference
Smego RA Jr et al: Actinomycosis. Clin Infect Dis 1998;26:1255. [PMID:
9686342]
+
240 Essentials of Diagnosis &Treatment
Nocardiosis
• Essentials of Diagnosis
• Nocardia asteroides and Nocardia brasiliensis are aerobic soil
bacteria causing pulmonary and systemic disease
• Malaise, weight loss, fever, night sweats, cough
• Pulmonary consolidation or thin-walled abscess; invasion through
chest wall possible
• Lobar infiltrates, air-fluid level, effusion by chest x-ray
• Delicate branching, gram-positive filaments by Gram stain, weakly
positive acid-fast staining; culture identifies specifically
• Disseminated form may occur with abscess in any organ; brain,
subcutaneous nodules most frequent
• Alveolar proteinosis, corticosteroid use, immunodeficiency predispose
to infection
• The above are all due to N asteroides; N brasiliensis causes lymphangitis
after skin inoculation and is common among gardeners
• Differential Diagnosis
• Actinomycosis
• Tuberculosis or atypical mycobacterial infections
• Other causes of pyogenic lung abscess
• Lymphoma
• Coccidioidomycosis
• Histoplasmosis
• Herpetic whitlow
• Bacterial lymphangitis (N brasiliensis)
• Treatment
• Parenteral and then oral trimethoprim-sulfamethoxazole for many
months
• Surgical drainage and resection may be needed
• Pearl
Lymphangitis unresponsive to beta-lactams. e~pecially in a person with
soil exposure, suggests N brasiliensis infection-but also herpetic whitlow.
Reference
Boiron Pet al: Nocardia, nocardiosis and mycetoma. Med Mycol 1998,36(Suppl
1):26. [PMID: 9988489]
+
Chapter 8 Infectious Diseases 241
Tuberculous Meningitis (Mycobacterium tuberculosis)
• Essentials of Diagnosis
• Insidious onset of listlessness, irritability, headaches
• Meningeal signs, cranial nerve palsies
• Tuberculous focus evident elsewhere in half
• Cerebrospinal fluid with lymphocytic pleocytosis, low glucose,
and high protein; culture positive for acid-fast bacilli in many but
not all
• Chest x-ray commonly reveals abnormalities compatible with
pulmonary tuberculosis
• Differential Diagnosis
• Chronic lymphocytic meningitis due to fungi, brucellosis, leptospirosis,
HlV infection, neurocysticercosis
• Carcinomatous meningitis
• Unsuspected head trauma with subdural hematoma
• Drug overdose
• Psychiatric disorder
• Sarcoidosis
• Treatment
• Empiric antituberculous therapy essential in proper clinical setting
• Concomitant corticosteroids reduce long-term complications
• Pearl
Striking hypoglycorrhachia in lymphocytic meningitis means tuberculous
meningitis until di,proved; acellular hypoglycorrhachia should be
assumed to be hypoglycemia until proved otherwise by blood glucose.
Reference
Thwaites G et al: Tuberculous meningitis. J Neurol Neurosurg Psychiatry
2000;68:289. [PMlD: 10675209]
242 Essentials of Diagnosis &Treatment
leprosy (Mycobacterium leprae)
+
• Essentials of Diagnosis
• A chronic infection due to M leprae
• Pale, anesthetic macular (tuberculoid) or infiltrative erythematous
(lepromatous) skin lesions
• Superficial nerve thickening with associated sensory changes;
progression slow and symmetric (lepromatous) or sudden and
asymmetric (tuberculoid)
• Skin test negative (lepromatous) or positive (tuberculoid)
• History of residence in endemic area during childhood; mode of
transmission probably is respiratory
• Acid-fast bacilli in skin lesions or nasal scrapings; characteristic
histologic nerve biopsy
• Lepromatous type occurs in patients with defective cellular immunity,
organisms numerous in tissue specimens; bacilli sparse in
tuberculoid disease
• Differential Diagnosis
• Lupus erythematosus
• Sarcoidosis
• Syphilis
• Erythema nodosum
• Erythema multiforme
• Vitiligo
• Neuropathy due to other causes, particularly amyloidosis
• Cutaneous tuberculosis
• Scleroderma
• Syringomyelia
• Treatment
• Combination therapy for months or years, including dapsone,
rifampin, and c10fazimine
• Pearl
M leprae can be grawn experimentally only in the armadillo foot pad.
Reference
HaimanotRTetal: Leprosy. CUff Opin NeuroI2000;13:317. [PMID: 10871258]
Oncologic Diseases
Carcinoma of the Head and Neck
• Essentials of Diagnosis
• Most common between ages 50 and 70; occurs in heavy smokers,
with alcohol as an apparent cocarcinogen
Early hoarseness in true cord lesions; sore throat, otalgia fairly
common; odynophagia, hemoptysis indicate more advanced
disease
• Comorbid lung cancer in some patients; may appear clinically up
to several years later
• Lesions found by physical examination or direct or indirect laryngoscopy;
regional lymphadenopathy common at presentation
• Differential Diagnosis
• Chronic laryngitis, including reflux laryngitis
• Laryngeal tuberculosis
• Myxedema
• Vocal cord paralysis due to laryngeal nerve palsy caused by left
hilar lesion
• Serous otitis media
• Herpes simplex
• Treatment
• Treatment varies by stage and tumor location and may include
surgery, radiation, radiosensitizing chemotherapy, or combinations
of above
• Chemotherapy may provide palliative benefit for metastatic or
recurrent disease
• Smoking cessation crucial for increasing treatment efficacy and
preventing second malignancies
• Pearl
The typical head-neck squamous cancer remains undiagnosed for
9 months after patient or physician awareness ofthe first symptom or
sign.
Reference
Correa AJ et al: Current options in management of head and neck cancer
patients. Med Clin North Am 1999;83:235. [PMID: 9927972]
243
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
244 Essentials of Diagnosis & Treatment
Colorectal Carcinoma
• Essentials of Diagnosis
• Risk factors include colonic polyposis, Lynch syndrome (hereditary
nonpolyposis colon cancer), and ulcerative colitis
• Altered bowel habits, rectal bleeding from left-sided carcinoma;
occult, blood in bowel movements; iron deficiency anemia in rightsided
lesions
• Palpable abdominal or rectal mass in minority
• Characteristic barium enema or colonoscopic appearance; tissue
biopsy is diagnostic
Elevated carcinoembryonic antigen (CEA) useful as marker of
disease recurrence in patients with elevated CEA at diagnosis but
is not useful as a diagnostic tool
• Differential Diagnosis
• Hemorrhoids
• Diverticular disease
• Benign colonic polyps
• Peptic ulcer disease
• Ameboma
• Functional bowel disease
Iron deficiency anemia due to other causes
• Treatment
• Dukes staging predicts prognosis
• Surgical resection for cure, also for palliation
• Adjuvant chemotherapy recommended for those with significant
risk of recurrence based on unfavorable Dukes stage after potentially
curative surgery
• Combination chemotherapy palliative for distant metastatic disease
Radiation with concurrent chemotherapy useful adjuvant to surgery
for rectal cancer
• Chemotherapy and radiotherapy curative in majority of localized
anal cancers without need for surgery
• Screening with colonoscopy will probably prove superior to flexible
sigmoidoscopy
• Pearl
Patients with Streptococcus bovis endocarditis have colonic neoplasia
until proved otherwise.
Reference
Rudy DR et al: Update on colorectal cancer. Am Fam Physician 2000;61 :1759.
[PMJD: 10750881]
Chapter 9 Oncologic Diseases 245
Hepatocellular Carcinoma
+
• Essentials of Diagnosis
• Most common visceral malignancy worldwide; usually asymptomatic
until disease advanced
Alcoholic cirrhosis, chronic hepatitis B or C, and hemochromatosis
are risk factors
• Abdominal enlargement, pain, jaundice, weight loss
• Hepatomegaly, abdominal mass; rub or bruit heard over right
upper quadrant in some
Anemia or erythrocytosis; liver function test abnormalities
Dramatic elevation in alpha-fetoprotein (AFP) helpful in diagnosis,
though significant percentage have normal AFPs
• Tendency to ascent hepatic vein and inferior vena cava
• Angiography (though rarely performed) with characteristic abnormality;
CT or MRI suggests diagnosis; tissue biopsy for confirmation
• Differential Diagnosis
• Benign liver tumors: hemangioma, adenoma, focal nodular hyperplasia
• Bacterial hepatic abscess
Amebic liver cyst
• Metastatic tumor
• Treatment
• Therapeutic options often limited by severe underlying liver disease;
no surgical option if cirrhosis is present in remainder of Iiver
• Surgical resection thought best curative option if lesions are resectable
and patient is operative candidate
Liver transplant may be curative in small percentage of highly
selected patients
• Many intralesional therapies being developed for unresectable
disease, though indications and ti ming of these interventions are
not well established
• Little benefit from chemotherapy in advanced disease
• Pearl
In a patient with known cirrhosis and a normal hematocrit, think hepatocellular
carcinoma-it's the second most common tumor (after renal
cell) to elaborate erythropoietin and pseud011017nalizes the anemia typical
ofcirrhosis.
Reference
Ulmer SC: Hepatocellular carcinoma. A concise guide to its status and management.
Postgrad Med 2000;107:117. [PMID: 10844947]
+
246 Essentials of Diagnosis &Treatment
Malignant Tumors of the Bile Ducts
• Essentials of Diagnosis
• Predisposing factors include choledochal cysts, primary sclerosing
cholangitis, ulcerative colitis with sclerosing cholangitis, Clonorchis
sinensis infection
• Jaundice, pruritus, anorexia, right upper quadrant pain
• Hepatomegaly, ascites, right upper quadrant tenderness
• Dilated intrahepatic bile ducts by ultrasound or CT scan
• Retrograde endoscopic cholangiogram characteristic; tissue biopsy
is diagnostic
• Hyperbilirubinemia (conjugated), markedly elevated alkaline
phosphatase and cholesterol
• Differential Diagnosis
• Choledocholithiasis
• Drug-induced cholestasis
• Cirrhosis
• Chronic hepatitis
• Metastatic hepatic malignancy
• Pancreatic or ampullary carcinoma
• Biliary stricture
• Treatment
• Palliative surgical bypass of biliary flow
• Stent bypass of biliary flow in selected patients
• Pancreaticoduodenectomy for resectable distal duct tumors curative
in minority
• Pearl
Half of cholangiocarcinoma patients have had ulcerative colitis,
though colectomy doesn't reduce the risk; a far smaller number 0
patients with ulcerative colitis have bile duct tumors.
Reference
Molmenti EP et al: Hepatobiliary malignancies. Primary hepatic malignant neoplasms.
Surg Clin North Am 1999;79:43. [PMlD: 10073181]
+
Chapter 9 Oncologic Diseases 247
Carcinoma of the Pancreas
• Essentials of Diagnosis
• Peak incidence in seventh decade; more common in blacks, patients
with chronic pancreatitis, and, debatably, diabetes mellitus
• Upper abdominal pain with radiation to back, weight loss, diarrhea,
pruritus, thrombophlebitis; painless jaundice, with symptoms
depending on where tumor is located, most being in the head
of the pancreas
Palpable gallbladder or abdominal mass in some
Elevated amylase with liver function abnormalities; anemia,
hyperglycemia, or frank diabetes in minority
• Dilated common hepatic ducts by ultrasound or endoscopic retrograde
cholangiogram
• CT, MRl, and endoscopic ultrasound may delineate extent of disease
and guide biopsy
• Often, true extent of disease not appreciated before exploratory
laparotomy
• Differential Diagnosis
• Choledocholithiasis
• Drug-induced cholestasis
• Hepatitis
• Cirrhosis
• Carcinoma of ampulla of Vater
• Treatment
• Surgical diversion for palliation in most cases
Radical pancreaticoduodenal resection for disease limited to head
of pancreas or periampullary zone (Whipple procedure) curative
in rare cases, but more so in ampullary tumors
• Chemotherapy, radiation, or combination in patients with advanced
local disease may improve outcomes
• Chemotherapy for metastatic disease may improve quality of life
• Pearl
A palpable periumbilical node-Sister Mary Joseph's node-was
described by a scrub nurse at the Mayo Clinic, who noticed it while preoperatively
sterilizing the abdominal walls ofafflicted patients.
Reference
Lillemoe KD et al: Pancreatic cancer: state-of-the-art care. CA Cancer J Clin
2000;50:24 I. [PMlD: 10986966]
248 Essentials of Diagnosis &Treatment
Carcinoma of the Female Breast
• Essentials of Diagnosis
• Increased incidence in those with a family history of breast cancer
and in nulliparous or late-childbearing women
• Painless lump, often found by the patient; nipple or skin changes
over breast (peau d'orange, redness, ulceration) later findings;
axillary mass, malaise, or weight loss even later findings
• Minority found by mammography
• Metastatic disease to lung, bone, or central nervous system may
dominate clinical picture
• Staging based on size of tumor, involvement oflymph nodes, and
presence of metastases
+
• Differential Diagnosis
• Mammary dysplasia (fibrocystic disease)
• Benign tumor (fibroadenoma, ductal papilloma)
• Fat necrosis
• Mastitis
• Thrombophlebitis (Mondor's disease)
• Treatment
• Treatment decisions require careful consideration of stage and
other prognostic factors
• Resection (Iumpectomy plus radiation therapy versus modified
radical mastectomy) in early-stage disease
• Adjuvant chemotherapy or hormonal therapy recommended for
many with completely resected disease except those at very low
risk for recurrence
• Menopausal and tumor hormone receptor status dictate best adjuvant
therapy
• Metastatic disease is incurable, but treatment with hormonal
manipulation, chemotherapy, radiation, and monoclonal antibody
therapy; may provide long-term remission ordisease stahilization
• Pearl
This is the most feared disease among American women; emotional
support is as crucial as therapeutic care.
Reference
Sainsbury JR et al: ABC of breast diseases: breast cancer. BMJ 2000;321 :745.
[PMTD: 1099991 J]
+
Chapter 9 Oncologic Diseases 249
Carcinoma of the Male Breast
• Essentials of Diagnosis
• Painless lump or skin changes of breast
• Nipple discharge, retraction or ulceration, palpable mass, gynecomastia
• Staging as in women
• Differential Diagnosis
• Gynecomastia due to other causes
• Benign tumor
• Treatment
• Modified radical mastectomy with staging as in women
• For metastatic disease, endocrine manipulation (physical or chemical
castration) with tamoxifen or related compounds, arninoglutethimide,
or corticosteroids often quite effective
• Pearl
This constitutes 1% ofall breast cancer, but it is invariably diagnosed
later in its course because men are neither suspected nor screened.
Reference
Donegan WL et al: Breast cancer in men. Surg Clin North Am 1996;76:343.
[pMID: 86 J0268]
+
250 Essentials of Diagnosis & Treatment
Cervicallntraepithelial Neoplasia
(Dysplasia or Carcinoma in Situ of the Cervix)
• Essentials of Diagnosis
• Associated in some with human papillomavirus infection, excessive
sexual activity
• Asymptomatic in many
• Cervix appears grossly normal with dysplastic or carcinoma in
situ cells by cytologic smear preparation
• Culdoscopic examination with coarse punctate or mosaic pattern
of surface capillaries, atypical transformation zone, and thickened
white epithelium
• Iodine-nonstaining (Schiller-positive) squamous epithelium is
typical
• Differential Diagnosis
• Cervicitis
• Treatment
• Varies depending upon degree and extent of cervical or intraepithelial
neoplasia; thus, staging crucial
• Observation for mild dysplasia
• Cryosurgery or CO2 laser vaporization for moderate dysplasia
• Cone biopsy or hysterectomy for severe dysplasia or carcinoma
in situ
• Repeat examinations to detect recurrence
• Pearl
One ofthe few disorders for which screening with Pap smear Iws made
an important difference.
Reference
Cox JT: Management of cervical intraepithelial neoplasia. Lancet 1999;353:857.
[PMID: 10093973]
Chapter 9 Oncologic Diseases 251
Cancer of the Cervix
+
• Essentials of Diagnosis
• Abnormal uterine bleeding, vaginal discharge, pelvic or abdominal
pain
• Cervical lesion may be visible on inspection as tumor or ulceration
Vaginal cytology is usually positive; must be confirmed by biopsy
• CT or MRl of abdomen and pelvis, examination under anesthesia
useful for staging disease
• Differential Diagnosis
• Cervicitis
• Chronic vaginitis or infection (tuberculosis, actinomycosis)
• Sexually transmitted diseases (syphilis, lymphogranuloma venereum,
chancroid, granuloma inguinale)
• Aborted cervical pregnancy
• Treatment
• Stage-dependent and requires input of surgeons, medical oncologists,
and radiation oncologists
• Radical or extended hysterectomy curative in patients with earlystage
disease
• Combination of radiation therapy and radiosensitizing chemotherapy
curative in majority of patients with localized disease not
amenable to primary resection
• Role of surgery following chemotherapy and radiotherapy still
being defined
• Combination chemotherapy for metastatic disease has significant
response rate, but unclear magnitude of benefit on survival
• Pearl
Adherence to screening guidelines can prevent the invasive stage o/this
disease.
Reference
Canavan TP et al: Cervical cancer. Am Fam Physician 2000;61: 1369. [pMID:
10735343]
+
252 Essentials of Diagnosis & Treatment
Endometrial Carcinoma
• Essentials of Diagnosis
• Higher incidence in obesity, diabetes, nulliparity, polycystic
ovaries, and women receiving tamoxifen as adjuvant therapy for
breast cancer
• Abnormal uterine bleeding, pelvic or abdominal pain
• Uterus frequently not enlarged on palpation
• Endometrial biopsy or curettage is required to confirm diagnosis
after negative pregnancy test; vaginal cytologic examination is
negative in high percentage of cases
• Examination under anesthesia, chest x-ray, CT, or MRl required
in staging
• Differential Diagnosis
• Pregnancy, especially ectopic
• Atrophic vaginitis
• Exogenous estrogens
• Endometrial hyperplasia or polyps
• Other pelvic or abdominal neoplasms
• Treatment
• Hysterectomy and salpingo-oophorectomy for well-differentiated
or localized tumors
• Combined surgery and radiation for poorly differentiated tumors,
cervical extension, deep myometrial penetration, and regional
lymph node involvement
• Radiotherapy for unresectable localized malignancies
• Palliative chemotherapy may benefit those with metastatic disease,
though role and optimal regimen still being defined
• Progestational agents may help some women with metastatic
disease
• Pearl
Unlike cervical cancers, screening is less helpjitt than having a high
index ofsuspicion in at-risk patients.
Reference
Canavan TP et aI: Endometrial cancer. Am Fam Physician 1999;59:3069.
[PMID: 10392590]
Chapter 9 Oncologic Diseases 253
Carcinoma of the Vulva
+
• Essentials of Diagnosis
• Prolonged vulvar irritation, pruritus, local discomfort, slight bloody
discharge
• History of genital warts common; association with human papillomavirus
established
• Early lesions may suggest chronic vulvitis
• Late lesions may present as a mass, exophytic growth, or firm
ulcerated area in vulva
• Biopsy makes diagnosis
• Differential Diagnosis
• Sexually transmitted diseases (syphilis, lymphogranuloma venereum,
chancroid, granuloma inguinale)
• Crohn's disease
• Benign tumors (granular cell myoblastoma)
• Reactive or eczematoid dermatitis
• Vulvar dystrophy
• Treatment
• Local resection for cases of in situ squamous cell carcinoma
• Wide surgical excision with lymph node dissection for invasive
carcinoma
• Pearl
This disorder may be diagnosed late because of its similarity to sexually
transmitted diseases.
Reference
Homesley HD: Management of vulvar cancer. Cancer 1995;76(10 Suppl):2159.
[PMTD: 8635016]
+
254 Essentials of Diagnosis & Treatment
Ovarian Tumors
• Essentials of Diagnosis
• Abdominal distention, pelvic pain, vaginal bleecling
• Ascites, abdominal mass or pelvic pain
• Ultrasonography or CT scan of the abdomen or pelvis delineates
extent of disease
• Laparoscopy or laparotomy to obtain tissue from mass or ascites
for cytologic examination
• CA 125 (a tumor marker) useful to monitor for recurrence, less
valuable for screening
• Differential Diagnosis
• Uterine leiomyoma
• EndometIiosis
• Tubal pregnancy
• Pelvic kidney
• Retroperitoneal tumor or fibrosis
• Colorectal carcinoma
• Chronic pelvic inAammatory disease (especially tuberculosis)
• Benign ovarian masses
• Treatment
• Premenopausal women with small ovarian masses can be observed
with a trial of ovulation suppression for two cycles followed by
repeat examination
• Simple excision with ovarian preservation for many benign cell
types
Unilateral salpingo-oophorectomy for certain cell types in younger
women
Hysterectomy with bilateral salpingo-oophorectomy in postmenopausal
women, or premenopausal women with resectable disease
not candidates for more conservative surgery
Adjuvant chemotherapy for most patients with resected disease
• Cytoreductive surgery followed by combination chemotherapy
for women with advanced disease without distant metastases
• Combination chemotherapy has high response rate and may provide
durable remissions in women with metastatic disease
• Pearl
Be aware ofthis illness in overweight women-ascites may be difficult
to detect on examination.
Reference
Nahhas WA: Ovarian cancer. Current outlook on this deadly disease. Postgrad
Med 1997; 102: 112. [PMTD: 9300021]
Chapter 9 Oncologic Diseases 255
+
Gestational Trophoblastic Neoplasia
(Hydatidiform Mole &Choriocarcinoma)
• Essentials of Diagnosis
• Uterine bleeding in first trimester
• Utems larger than expected for duration of pregnancy
• No fetus demonstrated by ultrasound with sometimes characteristic
findings of mole; excessively elevated levels ofsemm ~-hCG
for gestational duration of pregnancy
• Vesicles may be passed from vagina
• Preeclampsia seen in first trimester
• Differential Diagnosis
• Multiple pregnancy
• Threatened abortion
• Ectopic pregnancy
• Treatment
• Suction curettage for hydatidifonn mole
• For nonmetastatic malignant disease, single-agent chemotherapy
(eg, methotrexate or dactinomycin) very effective, but the role of
hysterectomy is uncertain
• For metastatic disease, single-agent or combination chemotherapy
depending upon clinical setting
• Follow quantitative ~-hCG until negative and then frequently for
surveillance of tumor recurrence
• Pearl
Remember an ectopic mole source in a young woman who has hyperthyroidism
without a palpable thyroid gland.
Reference
Berkowitz RS et al: Gestational trophoblastic disease. Cancer 1995;76(10
Suppl):2079. [pMID: 8635004]
+
256 Essentials of Diagnosis & Treatment
Thyroid Cancer
• Essentials of Diagnosis
• History of irradiation to neck in some patients
• Often hard, painless nodule; dysphagia or hoarseness occasionally
• Cervical lymphadenopathy when local metastases present
• Thyroid function tests normal; nodule is characteristically stippled
with calcium on x-ray, cold by radioiodine scan, and solid by
ultrasound; does not regress with thyroid hormone administration
• Differential Diagnosis
• Thyroiditis
• Other neck masses and other causes of lymphadenopathy
• Thyroglossal duct cyst
• Benign thyroid nodules
• Treatment
• Fine-needle aspiration biopsy best differentiates benign from malignant
nodules
• Total thyroidectomy for carcinoma; radioactive iodine postoperatively
for selected patients with iodine-avid metastases; combination
chemotherapy in anaplastic tumors
• Prognosis related to cell type and histology; papillary carcinoma
offers excellent outlook, anaplastic the worst
• Medullary thyroid cancer is typically refractory to chemotherapy
and radiation; diagnosable by calcitonin elevation in MEN syndromes
• Pearl
In patients who had thymus radiation during childhood-a common
practice in past years-a thyroid nodule is malignant until proved otherwise.
Reference
Rossi RL et al: Thyroid cancer. Surg Clin North Am 2000;80:571. [PMID:
10836007]
Chapter 9 Oncologic Diseases 257
Carcinoma of the Prostate
+
• Essentials of Diagnosis
• More common and seemingly more aggressive in blacks
• Exact role of screening uncertain; may prove to be more useful in
middle-aged men, especially blacks
• Symptoms of prostatism more often absent than present; bone
pain (especially back) if metastases present; asymptomatic in
many, however
• Stony, hard, irregular prostate palpable, usually lateral part of
gland
• Osteoblastic osseous metastases visible by plain radiograph
• Prostate-specific antigen (PSA) is age-dependent and is elevated
in older patients with benign prostatic hyperplasia and also acute
prostatitis; reliably predicts extent of neoplastic disease and
recurrence after prostatectomy
• Differential Diagnosis
• Benign prostatic hyperplasia (may be associated)
• Scarring secondary due to tuberculosis or calculi
• Urethral stricture
• Neurogenic bladder
• Treatment
• Providers must apprise patients of the probability of posttherapeutic
erectile dysfunction, urinary incontinence
• Radiation therapy (external beam, brachytherapy, or combination)
or radical prostatectomy, ideally nerve-sparing for localized
disease
• Radiation or surgical therapy for local nodal metastases in selected
patients after prostatectomy
• Androgen ablation (chemical or surgical) for metastatic disease,
though exact timing of initiation of therapy (at diagnosis or at
onset of symptoms) is unclear
• Combination chemotherapy may benefit selected patients with
hormone-refractory metastatic disease
• Pearl
About 1% ojprostate tumors-most ojthese are small-cell carcinomasare
not adenocarcinoma and thus do not express PSA.
Reference
Klotz L: Honnone therapy for patients with prostate carcinoma. Cancer
2000;88(12 Suppl):3009. [PMlD: 10898345]
258 Essentials of Diagnosis &Treatment
Tumors of the Testis
• Essentials of Diagnosis
• Painless testicular nodule; peak incidence at age 20-35
• Testis does not transilluminate
• Gynecomastia, premature virilization in occasional patients
• Tumor markers (AFP, LDH, hCG) useful in diagnosis, monitoring
response to therapy, and surveillance for relapse
• Pure seminoma produces hCG only, while nonseminomatous
germ cell tumors may produce hCG and AFP
+
• Differential Diagnosis
• Genitourinary tuberculosis
• Syphilitic orchitis
• Hydrocele
• Spermatocele
• Epididymitis
• Treatment
• Orchiectomy, with lumbar and inguinal lymph nodes examined
for staging
• Additional radical resection of iliolumbar nodes indicated unless
tumor is a seminoma for which radiation therapy is treatment of
choice following surgery
• Postsurgical radiation therapy also useful for other malignant cell
types
• Platinum-based chemotherapy curative in appreciable majority of
patients with advanced or metastatic disease
• Pearl
Gne ofthe great stories in oncology, with remarkable therapies resulting
in many years oflife saved.
Reference
Kinkade S: Testicular cancer. Am Pam Physician 1999;59:2539. [PMID:
10323360]
Chapter 9 Oncologic Diseases 259
+
Carcinoma of the Bladder
(Transitional Cell Carcinoma)
• Essentials of Diagnosis
• More common in men over 40 years of age; predisposing factors
include smoking and alcohol as well as chronic Schistosoma
haematobium infection, exposure to certain industrial toxins, or
previous cyclophosphamide therapy
• Microscopic or gross hematuria with no other symptoms is the
most common presentation
• Suprapubic pain, urgency, and frequency when concurrent infection
present
• Occasional uremia if both ureterovesical orifices obstructed
• Tumor visible by cystoscopy
• Differential Diagnosis
• Other urinary tract tumor
• Acute cystitis
• Renal tuberculosis
• Urinary calculi
• Glomerulonephritis or interstitial nephritis
• Treatment
• Endoscopic transurethral resection for superficial or submucosal
tumors; intravesical chemotherapy reduces the likelihood of recurrence
• Radical cystectomy standard with muscle-invasive tumors, though
less morbid procedures with intensive follow-up may provide similar
outcomes
Role of adjuvant chemotherapy or radiation for completely resected
patients unclear, but generally offered to those at high risk
of recurrence
• Combination chemotherapy for metastatic disease has a high responsc
ratc and may bc curativc in a small pcrccntagc of paticnts
• Pearl
Remember Kaposi's sarcoma ofthe bladder in an AIDS patient with a
urinary catheter and gross hematuria; it usually (not always) presents
in association with cutaneous disease.
Reference
van der Meijden AP: Bladder cancer. BMJ 1998;317: 1366. [PMID: 99030215]
+
260 Essentials of Diagnosis & Treatment
Adenocarcinoma of the Kidney
(Renal Cell Carcinoma; Hypernephroma)
• Essentials of Diagnosis
• Dubbed the internist's tumor because of its pleomorphic clinical
manifestations
• Gross or microscopic hematuria, back pain, fever, weight loss,
night sweats
• Flank or abdominal mass may be palpable
• When flank pain, hematuria, and palpable mass-the "too-late
triad"-are present, only 15% are curable
• Anemia in 30%, erythrocytosis in 3%; hypercalcemia, hypoglycemia
sometimes seen
• Frequent tumor or tumor thrombus invasion of renal vein and
ascending inferior vena cava, on occasion causing superior vena
cava syndrome
• Renal ultrasound, CT, or MRl reveals characteristic lesion
• Differential Diagnosis
• Simple cyst
• Polycystic kidney disease
• Single complex renal cyst; but 70% of these are malignant
• Renal tuberculosis
• Renal calculi
• Renal infarction
• Endocarditis
• Treatment
• Nephrectomy curative for patients with early stage lesions
• Poor response to chemotherapy or radiation in metastatic disease
• Small response rate to combination bio-chemotherapy (interleukin
2 plus cytotoxic agents), though very toxic
• Resection of primary lesion has been documented to result in
regression of metastases on rare occasions
• Nonmyeloablating allogeneic bone marrow transplantation has
significant response rate in highly selected patients
• Pearl
A small proportion ofpatients have a nonmetastatic hepatopathy, with
elevation ofalkaline phosphatase; this abnonnality does not imply inoperability
and disappears with resection ofthe tumor.
Reference
Motzer RJ et al: Renal-cell carcinoma. N Engl J Med 1996;335:865. [PMID:
8778606]
+
Chapter 9 Oncologic Diseases 261
Malignant Tumors of the Esophagus
• Essentials of Diagnosis
• Progressive dysphagia-initially during ingestion of solid foods,
later with liquids; progressive weight loss and inanition ominous
• Smoking, alcoholism, chronic esophageal reAux with Barrett's
esophagus, achalasia, caustic injury, and asbestos are risk factors
• Noninvasive imaging (barium swallow, CT scan) suggestive,
diagnosis confirmed by endoscopy and biopsy
• Staging of disease aided by endoscopic ultrasound
• Squamous histology more common, though incidence of adenocarcinoma
increasing rapidly in Western countries for unclear
reasons
• Differential Diagnosis
• Benign tumors of the esophagus
• Benign esophageal stricture or achalasia
• Esophageal diverticulum
• Esophageal webs
• Achalasia (may be associated)
• Globus hystericus
• Treatment
• Combination chemotherapy and radiotherapy or surgery for localized
disease, though long-tenn remission or cure is achieved
in only 10-15%
• Dilation or esophageal stenting may palliate advanced disease;
little role for chemotherapy or radiation in advanced or metastatic
disease
• Pearl
Dysphagia is one ofthe few symptoms in medicine for which anatomic
correlation always exists-too often it represents carcinoma.
Reference
Lerut T et al: Treatment of esophageal carcinoma. Chest 1999;116(6
Suppl):463S. [PMID: 10619509]
+
262 Essentials of Diagnosis & Treatment
Carcinoma of the Stomach
• Essentials of Diagnosis
• Few early symptoms, but abdominal pain not unusual; late complaints
include dyspepsia, anorexia, nausea, early satiety, weight
loss
• Palpable abdominal mass (late)
• Iron deficiency anemia, fecal occult blood positive; achlorhydria
present in minority of patients
• Mass or ulcer visualized radiographically; endoscopic biopsy and
cytologic examination diagnostic
• Associated with atrophic gastritis, Helicobacter pylori; role of
diet, previous partial gastrectomy controversial
• Differential Diagnosis
• Benign gastric ulcer
• Gastritis
• Functional or irritable bowel syndrome
• Other gastric tumors, eg, leiomyosarcoma, lymphoma
• Treatment
• Resection for cure; palliative resection with gastroenterostomy in
selected cases
Adjuvant chemotherapy may improve long-term survival in highrisk
patients post surgery and may achieve remission in a minority
of patients with metastatic disease
• Pearl
A gastric ulcer with histamine-fast achlorhydria is adenocarcinoma in
100% ofcases.
Reference
Scheiman JM et al: Helicobacter pylori and gastric cancer. Am J Med
1999; 106:222. [PM1D: 10230753]
+
Chapter 9 Oncologic Diseases 263
Bronchogenic Carcinoma
• Essentials of Diagnosis
• Smoking most important cause, concomitant asbestos exposure
synergistic; also associated with second-hand smoke
• Chronic cough, dyspnea; chest pain, hoarseness, hemoptysis,
weight loss; may be asymptomatic, however
• Examination depends on disease stage; localized wheezing, clubbing,
superior vena cava syndrome in some
Enlarging mass, infiltrate, atelectasis, pleural effusion, or cavitation
by chest x-ray; peripheral coin lesions in a minority
Diagnostic: presence of malignant cells by sputum or pleural fluid
cytology or on histologic examination of tissue biopsy
• Metastases to other organs or paraneoplastic effects may produce
the initial symptoms
• Central nervous system metastases at time of diagnosis common
with small cell histology
• Differential Diagnosis
• Tuberculosis
• Pulmonary mycoses
Pyogenic lung abscess
• Metastasis from extrapulmonary primary tumor
• Benign lung tumor, eg, hamartoma
Noninfectious granulomatous disease
• Treatment
• Resection for appropriate non-small-cell carcinomas and all coin
lesions, assuming no evidence of spread or other primary
• Combination chemotherapy and radiation for limited-stage smallcell
carcinoma; may be curative
Prophylactic cranial radiation probably beneficial for those achieving
complete remission or excellent response with initial therapy
Palliative chemotherapy and radiation for metastatic non-small-cell
carcinoma
• Pearl
Of nonsmokers who develop this disorder, middle-aged women with
non-small cell cancer are the most common; take pulmonary symptoms
very seriously in this group.
Reference
Hoffman PC et al: Lung cancer. Lancet 2000;355:479. [PMID: 10841143]
+
264 Essentials of Diagnosis & Treatment
Pleural Mesothelioma
• Essentials of Diagnosis
• Insidious dyspnea, nonpleuritic chest pain, weight loss
• Dullness to percussion, diminished breath sounds, pleural friction
rub, clubbing
• Nodular or irregular unilateral pleural thickening, often with effusion
by chest radiograph; CT scan often helpful
• Pleural biopsy usually necessary for diagnosis, though malignant
nature of tumor only confirmed by natural history; pleural fluid
exudative and usually hemorrhagic
• Strong association with asbestos exposure, with usual latency
from time of exposure 20 years or more
• Differential Diagnosis
• Primary pulmonary parenchymal malignancy
• Empyema
• Benign pleural inflammatory conditions (posttraumatic, asbestosis)
• Treatment
• No consistently effective therapy currently available, though investigations
with combination surgery, radiotherapy, and chemotherapy
are under way
• One-year mortality rate> 75%
• Pearl
Consider this when empyema develops in patients irradiatedfor malignancy
years earlier-it's a rare complication.
Reference
Sterman DH et al: Advances in the treatment of malignant pleural mesothelioma.
Chest 1999;116:504. [PMID: 10453882]
Chapter 9 Oncologic Diseases 265
Primary Intracranial Tumors
+
• Essentials of Diagnosis
• Many different cell types; prognosis upon which one; half are
gliomas
• Most present with generalized or focal disturbances of cerebral
function: generalized symptoms include nocturnal headache,
seizures, and projectile vomiting; focal deficits relate to location
of the tumor
• CT or MR1 with gadolinium enhancement defines the lesion; posterior
fossa tumors are better visualized by MRI
• Biopsy is the definitive diagnostic procedure, distinguishes primary
brain tumors from brain abscess and other intracranial spaceoccupying
lesions such as metastases
Specific types:
• Glioblastoma multi forme: in strictest sense an astrocytoma, but
rapidly progressive with a poor prognosis
• Astrocytoma: More chronic course than glioblastoma, with a
variable prognosis
• Medulloblastoma: seen primarily in children and arises from roof
of fourth ventricle
• Cerebellar hemangioblastoma: patients usually present with disequilibrium
and ataxia, and occasional erythrocytosis
• Meningioma: compresses rather than invades adjacent neural
structures; usually benign
Primary cerebral lymphoma: usually in AIDS and other immunodeficient
states, though may occur rarely in immunocompetent
individuals
• Treatment
• Treatment depends upon the type and site of the tumor and the
condition of the patient
Resection to maximal extent possible is imponant predictor of
outcome in most central nervous system malignancies
• Radiation post surgery is mainstay of therapy
• Herniation treated with intravenous corticosteroids, mannitol,
and surgical decompression if possible
• Prophylactic anticonvulsants are also commonly given
• Pearl
A headache that awakens a patient from sleep should put this diagnosis
at the top ofthe list.
Reference
DeAngelis LM: Brain tumors. N Engl J Med 2001 ;344:114. [PMlD: 11150363]
10
Fluid, Acid-Base,
.. Electrolyte Disorders
Dehydration (Simple & Uncomplicated)
• Essentials of Diagnosis
• Thirst, oliguria
• Decreased skin turgor, especially on anterior thigh; dry mucous
membrane, postural hypotension, tachycardia
• Impaired renal function (BUN to creatinine ratio> 20), elevated
urinary osmolality and specific gravity, decreased urinary sodium
(fractional excretion of sodium is usually < 1%)
• Differential Diagnosis
• Hemorrhage
• Sepsis
• Gastrointestinal fluid losses
• Skin sodium losses associated with burns or sweating
• Renal sodium loss
• Adrenal insufficiency
• Nonketotic hyperosmolar state in type 2 diabetics
• Treatment
• Identify source of volume loss if present
• Replete with normal saline, blood, or colloid as indicated
• Half-normal saline may be substituted when blood pressure normalizes
• Pearl
Dry mucous membranes are more indicative ofmouth breathing than
ofdehydration.
Reference
Kleiner SM: Water: an essential but overlooked nutrient. J Am Diet Assoc
1999;99:200. [PMlD: 9972188]
266
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 267
Shock
• Essentials of Diagnosis
• History of hemorrhage, myocardial infarction, sepsis, trauma, or
anaphylaxis
• Tachycardia, hypotension, hypothermia, tachypnea
• Cool, sweaty skin with pallor; may be warm or flushed, however,
with early sepsis; clouded sensorium, altered level of consciousness,
seizures
• Oliguria, increased urinary osmolality and specific gravity, anemia,
disseminated intravascular coagulation, metabolic acidosis
may complicate
• Hemodynamic measurements depend upon underlying cause
• Differential Diagnosis
• Numerous causes of the syndrome, as noted above
• Adrenal insufficiency
• Treatment
• Correct cause of shock (ie, control hemorrhage, treat infection,
correct metabolic disease)
• Empiric broad-spectrum antibiotics often necessary
• Restore hemodynamics with fluids; vasopressor medications may
be required
Maintain urine output
• Treat contributing disease (eg, diabetes mellitus)
• Pearl
The patient appearing to be in shock but who is hypertensive may have
aortic dissection.
Reference
Dabrowski GP et al: A critical assessment of endpoints of shock resuscitation.
Surg Clin Nonh Am 2000;80:825. [pMID: 10897263]
268 Essentials of Diagnosis & Treatment
Hypernatremia
• Essentials of Diagnosis
• Usually severe thirst unless mentation altered; oliguria
• If hypovolemic, loose skin with poor turgor, tachycardia, hypotension
• Serum sodium> 145 meq/L, serum osmolality> 300 meq/L
caused by free water loss
• Affected patients usually include the very old, very young, critically
ill, or neurologically impaired
• Differential Diagnosis
• Diabetes insipidus, either idiopathic or drug-induced (eg, by
lithium)
• Loss of hypotonic Auid (insensible, diuretics, vomiting, diarrhea,
nasogastric suctioning)
• Salt intoxication
Volume resuscitation and continuation of normal saline
(155 meq/L) after euvolemia achieved
• Treatment
• Relatively rapid volume replacement followed by free water
replacement over 48-72 hours (beware of cerebral edema)
• Desmopressin acetate for central diabetes insipidus
• Pearl
In-patient mortality for a sodium> 150 mg/dL is approximately 50%.
Reference
Adrogue HJ et al: Hypernatremia. N Engl J Med 2000;342: 1493. [PMID:
10816188]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 269
Hyponatremia
• Essentials of Diagnosis
• Nausea, headache, weakness, irritability, mental confusion (especially
with serum sodium < 120 meq/L)
• Generalized seizures, lethargy, coma, respiratory arrest and death
may result
• Serum sodium < 130 meq/L; osmolality < 270 meq/L (hypotonic
hyponatremia); hypouricemia if SIADH or primary polydipsia is
the cause
• Differential Diagnosis
• Hypovolemic causes (thiazide diuretics, osmotic diuresis, adrenal
insufficiency, vomiting, diarrhea, fluid sequestration or thirdspacing)
• Hypervolemic causes (congestive heart failure, cirrhosis, nephrotic
syndrome, renal failure, pregnancy)
• Euvolemic causes (hypothyroidism, SIADH, adrenocortical insufficiency,
reset osmostat, primary polydipsia)
• Hypertonic or isotonic hyponatremia (hyperglycemia, intravenous
mannitol)
• Pseudohyponatremia (hypertriglyceridemia, paraproteinemia):
laboratory artifact
• Treatment
• Treat underlying disorder
• Corticosteroids empirically if adrenal insufficiency suspected
• Gradual correction (24-48 hours) ofsodium unless severe central
nervous system signs present (beware of central pontine myelinolysis)
• If hypovolemic, use saline
• If hypervolemic, use water restriction, diuretics, and normal saline
volume replacement of urine output
• Demeclocycline in selected patients with SJADH
• Pearl
A sodium less than 130 mg/dL, BUN less than 10 mg/dL, and hypouricemia
in a patient without liver, heart, or kidney disease is virtually
diagnostic ofS1ADH.
Reference
Adrogue HJ et al: Hyponatremia. N Engl J Med 2000;342: 1581. [PMID:
10824078]
270 Essentials of Diagnosis & Treatment
Hyperkalemia
• Essentials of Diagnosis
• Weakness or flaccid paralysis, abdominal distention, diarrhea
• Serum potassium> 5 meq/L
• Electrocardiographic changes: peaked T waves, loss of P wave
with sinoventricular rhythm, QRS widening, ventricular asystole,
cardiac arrest
• Differential Diagnosis
• Renal failure with oliguria
• Hypoaldosteronism (hyporeninism, potassium-sparing diuretics,
ACE inhibitors, adrenal disease, interstitial renal disease)
• Acidemia
• Burns, hemolysis
• Digitalis overdose
• Spurious from thrombocytosis, leukocytosis
• Treatment
• Emergency (cardiac toxicity, paralysis): intravenous bicarbonate,
calcium gluconate, glucose, and insulin
Dietary potassium restriction and sodium polystyrene sulfonate
or diuretic to lower body potassium subacutely
• Dialysis if oliguric renal failure or severe acidosis complicates
• Pearl
A "junctional" rhythm in a patient with marked renal insufficiency is
in all likelihood sinus rhythm with failure ofatrial depolarization.
Reference
Halperin ML et al: Potassium. Lancet 1998;352: 135. [PMID: 98336038]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 271
Hypokalemia
• Essentials of Diagnosis
• Usually asymptomatic
• Muscle weakness, lethargy, paresthesias, polyuria, anorexia, constipation
• May progress to weakness, muscle necrosis, ascending flaccid
paralysis, ileus
• Electrocardiographic changes: T wave flattening and ST depression
-+ development of prominent u waves -+ AV block -+ cardiac
arrest
• Serum potassium < 3.5 meq/L; metabolic alkalosis sometimes
concurrent
• Differential Diagnosis/Causes
• Diuretic use
• Alkalemia
• Hyperaldosteronism (adrenal adenoma, primary hyperreninism,
mineralocorticoid use, and European licorice ingestion)
• Magnesium depletion
• Hyperthyroidism
• Diarrhea
• Renal tubular acidosis (types I, II)
• Bartter's, Gitelman's, and Liddle's syndromes
• Familial hypokalemic periodic paralysis
• Severe dietary potassium restriction
• Treatment
• Identify and tTeat underlying cause
• Oral or intravenous potassium supplementation
• Pearl
Think ofhypokalemia in unexplained orthostatic hypotension.
Reference
Cohn IN et al: New guidelines for potassium replacement in clinical practice: a
contemporary review by the National Council on Potassium in Clinical Practice.
Arch Intern Met.! 2000;160:2429. [PMID: 10979053]
272 Essentials of Diagnosis & Treatment
Hypercalcemia
• Essentials of Diagnosis
• Polyuria and constipation; abdominal pain in some
• Thirst and dehydration
• Mild hypertension
• Altered mentation, hyporeflexia, stupor, coma
• Serum calcium> 10.2 mg/dL (corrected with concurrent serum
albumin)
• Renal insufficiency or azotemia, isosthenuria
• Shortened QT interval due to short ST segment, ventricular extrasystoles
• Differential Diagnosis
• Primary hyperparathyroidism
• Adrenal insufficiency
• Malignancy (multiple myeloma with osteoclast-activating factor;
other primary tumor or metastasis releasing parathyroid hormonerelated
peptide)
• Vitamin D intoxication
• Milk-alkali syndrome
• Sarcoidosis
• Tuberculosis
• Paget's disease of bone, especially with immobilization
• Familial hypocalciuric hypercalcemia
• Treatment
• Identify and treat underlying disorder
• Volume expansion, loop diuretics (once euvolemic)
• Glucocorticoids, calcitonin, bisphosphonates, and dialysis all useful
in certain instances
• Resection of parathyroid adenoma, if present
• Pearl
All hypercalcemia ofmalignancy is humoral in origin; bone metastases
not elaborating such humoral factors do not elevate calcium.
Reference
Body JJ: Current and future directions in medical therapy: hypercalcemia. Cancer,
2000;88( 12 Suppl):3054. [pMTD: 10898351]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 273
Hypocalcemia
• Essentials of Diagnosis
• Abdominal and muscle cramps, stridor; tetany and seizures
• Diplopia, facial paresthesias
• Positive Chvostek and Trousseau signs
• Cataracts if chronic, likewise basal ganglion calcifications
• Serum calcium < 8.5 mg/dL (corrected with concurrent serum
albumin); phosphate usually elevated; hypomagnesemia may
cause or complicate
• Electrocardiographic changes: prolonged QT interval; ventricular
arrhythmias, including ventricular tachycardia
• Differential Diagnosis
• Vitamin D deficiency and osteomalacia
• Malabsorption
• Hypoparathyroidism
• Hyperphosphatemia
• Hypomagnesemia
• Chronic renal failure
• Alcoholism
• Drugs (loop diuretics, aminoglycosides, foscarnet)
• Treatment
• Identify and treat underlying disorder
• For tetany, seizures, or arrhythmias, give calcium gluconate
intravenously
• Magnesium replacement if indicated
• Oral calcium and vitamin D supplements
• Phosphate-binding antacids if phosphate elevated
• Pearl
The prolonged QT ofhypocalcemia results from a lengthened ST segmcnt;
T wavcs arc /lonna!.
Reference
Reber PM et al: Hypocalcemic emergencies. Med Clin North Am 1995;79:
93. [PMTD: 7808098]
274 Essentials of Diagnosis & Treatment
Hyperphosphatemia
• Essentials of Diagnosis
• Few distinct symptoms
• Cataracts, basal ganglion calcifications in hypoparathyroidism
• Serum phosphate> 5 mg/dL; renal failure, hypocalcemia occasionally
seen
• Differential Diagnosis
• Renal failure
• Hypoparathyroidism
• Excess phosphate intake, vitamin D toxicity
• Phosphate-containing laxative use
• Cell destruction, rhabdomyolysis, respiratory or metabolic acidosis
• Multiple myeloma
• Treatment
• Treat underlying disease when possible
• Oral calcium carbonate to reduce phosphate absorption
• Hemodialysis if refractory
• Pearl
Overshoot hyperphosphatemiajrom therapy ojhypophosphatemia may
precipitate the acute onset ojtetany.
Reference
Weisinger JR et al: Magnesium and phosphorus. Lancet, 1998;352:391. [PMID:
9717944]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 275
Hypophosphatemia
• Essentials of Diagnosis
• Seldom an isolated abnormality
• Anorexia, myopathy, arthralgias
• Irritability, confusion, seizures, coma
• Rhabdomyolysis if severe
• Serum phosphate < 2.5 mg/dL, severe < I mg/dL; elevated creatine
kinase if rhabdomyolysis
• Hemolysis in severe cases
• Differential Diagnosis
• Hyperparathyroidism, hyperthyroidism
• Alcoholism
• Vitamin D-resistant osteomalacia
• Malabsorption, starvation
• Hypercalcemia, hypomagnesemia
• Correction of hyperglycemia
• Recovery from catabolic state
• Treatment
• Intravenous phosphate replacement when severe
• Oral phosphate supplements (unless hypercalcemic); be cautious
about overshooting
• Correct magnesium deficit, if present
• Pearl
Plwsphate levels even as low as 0-0.1 mg/dL are possible without clinical
manifestations.
Reference
Subramanian R et al: Severe hypophosphatemia. Pathophysiologic implications,
clinical presentations, and treatment. Medicine 2000;79:1. [PMID: 10670405]
276 Essentials of Diagnosis & Treatment
Hypermagnesemia
• Essentials of Diagnosis
• Weakness, hyporeflexia, respiratory muscle paralysis
• Confusion, altered mentation
• Serum magnesium> 3 mg/dL; renal insufficiency common; increased
uric acid, phosphate, potassium, and decreased calcium
may be seen
Increased PR interval ---7 heart block ---7 cardiac arrest
• Differential Diagnosis
• Renal insufficiency
• Excessive magnesium intake (food, antacids, laxatives, intravenous
administration)
• Treatment
• Correct renal insufficiency, if possible (volume expansion)
• Intravenous calcium chloride for severe manifestations (eg, electrocardiographic
changes, respi ratory arrest)
• Dialysis
• Pearl
Be cautious about magnesium-containing antacids-available OTCin
patients with renal insufficiency.
Reference
Weisinger JR et al: Magnesium and phosphorus. Lancet 1998;352:391. [PMID:
9717944]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 277
Hypomagnesemia
• Essentials of Diagnosis
• Muscle restlessness or cramps, athetoid movements, twitching or
tremor, convulsions or delirium
• Muscle wasting, hyperreAexia, positive Babinski sign, nystagmus,
hypertension
• Serum magnesium < 1.5 meq/L; decreased calcium, potassium
often seen
• Electrocardiographic changes: tachycardia, premature atrial or
ventricular beats, increased QT interval, ventricular tachycardia
or fibrillation
• Differential Diagnosis
• Inadequate dietary intake (ie, malnutrition)
• Hypervolemia
• Diuretics, cisplatin, aminoglycosides, amphotericin B
• Malabsorption or diarrhea
• Alcoholism
• Hyperaldosteronism, hyperthyroidism, hyperparathyroidism
• Respiratory alkalosis
• Treatment
• Identify and treat underlying cause
• Intravenous magnesium replacement followed by oral maintenance
• Calcium and potassium supplements if needed
• Pearl
Many manifestations of hypomagnesemia relate to the hypocalcemia
induced by resistance to parathyroid hormone.
Reference
Agus ZS: Hypomagnesemia. J Am Soc Nephrol 1999:10:1616. [PMID:
10405219]
278 Essentials of Diagnosis & Treatment
Respiratory Acidosis
• Essentials of Diagnosis
• Central to all is alveolar hypoventilation
• Confusion, altered mentation, somnolence
• Dyspnea, respiratory distress, pulmonary abnormalities with or
without cyanosis and asterixis
• Arterial Pcol increased; arterial pH decreased
• Lung disease may be acute (pneumonia, asthma) or chronic
(COPD)
• May occur in the absence of lung disease
• Differential Diagnosis
• Chronic obstructive lung disease or airway obstruction
• Central nervous system depressants
• Structural disorders of the thorax
• Myxedema
• Neurologic disorders, eg, Guillain-Barn§ syndrome
• Treatment
Address underlying cause
• Artificial ventilation if necessary to oxygenate, invasive or noninvasive
• Pearl
Hypoxemia must be corrected before ascribing mental status changes
to an elevated Peo2; it's the case in most hypercapnic patients.
Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders. First of
two parts. N Engl J Med 1998;338:26. [pMlD: 9414329]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 279
Respiratory Alkalosis
• Essentials of Diagnosis
• Lightheadedness, numbness or tingling of extremities, circumoral
paresthesias
• Tachypnea; positive Chvostek and Trousseau signs in acute hyperventilation;
carpopedal spasm and tetany
• Arterial pH> 7.45, Peo2 < 30 mm Hg
• Differential Diagnosis
• Restrictive lung disease or hypoxia
• Central nervous system lesion
• Pulmonary embolism
• Salicylate toxicity
• Anxiety
• End-stage cirrhosis
• Sepsis
• Pregnancy
• High-altitude residence
• Treatment
• Correct hypoxia or underlying ventilatory stimulant
• Increase ventilatory dead space (eg, breathe into paper bag, but
only in anxiety-induced hyperventilation)
• Pearl
A lowered Pco2 is a dependable early sign of bacteremia and sepsis
syndrome.
Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders. Second
of two parts. N Engl J Med 1998;338: 107. [PMID: 9420343]
280 Essentials of Diagnosis &Treatment
Metabolic Acidosis
• Essentials of Diagnosis
• Dyspnea, hyperventilation, respiratory fatigue
• Tachycardia, hypotension, shock (depending on cause)
• Acetone breath (in ketoacidosis)
• Anerial pH < 7.35, serum bicarbonate decreased; anion gap may
be normal or high; ketonuria
• Differential Diagnosis
• Ketoacidosis (diabetic, alcoholic, starvation)
• Lactic acidosis
• Poisons (methyl alcohol, ethylene glycol, salicylates, isopropyl
alcohol)
• Uremia
• Normal anion gap causes (diarrhea, renal tubular acidosis)
• Treatment
• Identify and treat underlying cause
• Correct volume, electrolyte status
• Bicarbonate therapy indicated in ethylene glycol or methanol toxicity,
renal tubular acidosis, debated for other causes
• Hemodialysis, mechanical ventilation if necessary
• Pearl
A low pH in diabetic ketoacidosis is not the cause ofan altered mental
status-Iryperosmolality is.
Reference
Forsythe SM et al: Sodium bicarbonate for the treatmem of lactic acidosis. Chest
2000; 117:260. [PMlD: 10631227]
+
Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 281
Metabolic Alkalosis
• Essentials of Diagnosis
• Weakness, malaise, lethargy; other symptoms depend on cause
• Hyporeflexia, tetany, ileus, muscle weakness
• Arterial pH> 7.45, Peo2 up to 45 mm Hg, and serum bicarbonate
> 30 meq/L; serum potassium and chloride usually low; hypoventilation
is seldom prominent irrespecti ve of pH
• Differential Diagnosis
• Loss of acid (vomiting or nasogastric aspiration)
• Diuretic overuse or any volume contraction
• Exogenous bicarbonate or base load
• Primary hyperaldosteronism states (hyperreninemia, ingestion of
some types of licorice, adrenal tumor or hyperplasia, Bartter's or
Gitelman's syndrome)
• Treatment
• Identify and correct underlying cause
• Replenish volume and electrolytes (use 0.9% sodium chloride)
• Hydrochloric acid rarely if ever needed
• Supplemental KCI in most
• Pearl
Vomiting causes mild metabolic alkalosis-only ifassociated with gastric
outlet obstruction are abnormalities marked.
Reference
Galla JH: Metabolic alkalosis. J Am Soc Nephrol 2000;11:369. [PMID:
10665945]
11
Genitourinary" Renal Disorders
GENITOURINARY DISORDERS
Tuberculosis of the Genitourinary Tract
• Essentials of Diagnosis
• Fever, malaise, night sweats, weight loss; evidence of pulmonary
tuberculosis in 50%
• Symptoms or signs of urinary tract infection may be present
• Nodular, indurated epididymis, testes, or prostate
• Sterile pyuria or hematuria without bacteriuria; white blood cell
casts can be seen with renal parenchymal involvement
• Positive culture of morning urine on one of three consecutive
samples
• Plain radiographs may show renal and lower tract calcifications
• Excretory urogram reveals "moth-eaten" calices, papillary necrosis,
and beading of ureters
• Occasionally, ulcers or granulomas of bladder wall at cystoscopy
• Differential Diagnosis
• Other causes of chronic urinary tract infections
• Interstitial nephritis, especially drug-induced
• Nonspecific urethritis
• Urinary calculi
• Epididymitis
• Bladder cancer
• Treatment
• Standard combination antituberculosis therapy
• Surgicill procedures for obstnlction ilnd severe hemorrhilge
• Nephrectomy for extensive destruction of the kidney
• Pearl
Tuberculosis of the genitourinary tract is the only descending urinary
tract infection; all others ascend.
Reference
Weiss SG 2nd et al: Genitourinary tuberculosis. Urology 1998;51:1033. [PMlD:
9609647]
282
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 11 Genitourinary & Renal Disorders 283
Bacterial Prostatitis
+
• Essentials of Diagnosis
• Acute bacterial prostatitis: fever, dysuria, urinary urgency and frequency,
perineal or suprapubic pain; very tender prostate; leukocytosis,
pyuria, bacteriuria, and hematuria
• Caused by Escherichia coli most commonly, also by Neisseria
gonorrhoeae, Chlamydia trachomatis, other gram-negative rods
(eg, proteus, pseudomonas) or gram-positive organisms (eg, enterococcus)
Prostatic massage may produce septicemia
• Chronic prostatitis: usually in older men, may be asymptomatic;
in some, urgency and frequency, dysuria, perineal or suprapubic
pain; prostate boggy, not tender; pathogenic organisms can persist
despi te treatment
• Expressed prostatic secretions demonstrate increased numbers of
leukocytes; culture often sterile
• Differential Diagnosis
• Urethritis
• Cystitis
Epididymitis
• Prostatodynia
Nonbacterial prostatitis
Perirectal abscess
• Treatment
• Symptomatic treatment with hot sitz baths, NSAIDs, and stool
softeners
For acute bacterial prostatitis in men under 35 years of age, treat
for N gonorrhoeae and C trachomatis infection
For acute bacterial prostatitis in men over age 35 years or homosexual
men, treat for Enterobacteriaceae with oral or intravenous
antihiotics (eg, trimethoprim-sulfamethoxazole or ciproAoxacin)
for 21 days
• For chronic bacterial prostatitis, treat for Enterobacteriaceae with
oral antibiotics (eg, trimethoprim-sulfamethoxazole or ciproAoxacin)
for 6-12 weeks; cure rate is often less than 50%
• Pearl
Trimethoprim-sulfameth<Jxazole achieves one ofthe highest intraprostatic
levels ofall antibiotics; an ideal drug for this process.
Reference
Nickel JC: Prostatitis: evolving management strategies. Urol Clin North Am
1999;26:737. [PMlD: 10584615]
284 Essentials of Diagnosis & Treatment
Urinary Calculi
• Essentials of Diagnosis
• Most common in the stone belt, extending from central Ohio
through mid Florida
• Sudden, severe colicky pain localized to the Aank, commonly
associated with nausea, vomiting, and fever; marked urinary
urgency and frequency if stone lodged at ureterovesical junction
Occasionally asymptomatic
• Hematuria in 90%, pyuria with concurrent infection; presence of
crystals in urine may be diagnostically helpful
Plain films of the abdomen (stone seen in 90%), spiral computerized
tomography, or sonography may be used to visualize location
of stone
• Depending on the metabolic abnormality, stones can be composed
of calcium oxalate or phosphate, struvite, uric acid, or cystine;
over 50% of patients develop recurrent stones
• Differential Diagnosis
• Acute pyelonephritis
• Chronic prostatism
• Tumor of genitourinary system
Renal tuberculosis
• Renal infarction
• Treatment
• Stones usually pass spontaneously with analgesia and hydration
• Antibiotics if concurrent infection present
Patient should filter urine and save stone for analysis
• Hydration is mainstay to prevent recurrence; also dietary change,
truazides, allopurinol, citrate, or a combination of these may be
used to prevent recurrence, depending on composition of the stone
• Refer to specialist for recurrent stones
• LithoLTipsy or surgical lithotomy may he necessary in refractory
cases
• Pearl
Analyze all stones: it is a rare noninvasive way to understand fully the
pathophysiology ofa disease process.
Reference
Saklayen MG: Medical management of nephrolithiasis. Med Clin North Am
1997;81:785. [pMID: 9167658]
Chapter 11 Genitourinary & Renal Disorders 285
Acute Epididymitis
+
• Essentials of Diagnosis
• Sudden pain and swelling of epididymis, with fever, dysuria, urinary
urgency, and frequency of less than 6 weeks duration
• Marked epididymal, testicular, or spermatic cord tenderness with
symptomatic relief upon elevation of scrotum (Prehn's sign)
• Leukocytosis, pyuria, bacteriuria
• Usually caused by Neisseria gonorrhoeae or Chlamydia traehomatis
in heterosexual men under age 40 and by Enterobacteriaceae
in homosexual men of all ages and heterosexual men over
age 40
• Doppler ultrasonography differentiates from testicular torsion
• Differential Diagnosis
• Testicular torsion
• Testicular tumor
• Orchitis
• Prostatitis
• Testicular trauma
• Treatment
• Empiric antibiotics after culture of urine obtained
• In men under age 40, treat for N gonorrhoeae and C traclwmatis
infection for 10-21 days
• Consider examination and treatment of sexual partners
In men over age 40, treat for Enterobacteriaceae for 21-28 days
• Analgesics and bed rest with elevation and support of scrotum
• Pearl
Have a low threshold for ordering a VDRL and testing for HIV.
Reference
National guideline for the management of epididymo-orchitis. Clinical Effectiveness
Group (Association of Genitourinary Medicine and the Medical
Society for the Study of Venereal Diseases). Sex Transm Infect 1999;
75(Suppll):S51. [PMID: 10616385]
286 Essentials of Diagnosis & Treatment
Testicular Torsion
• Essentials of Diagnosis
• Usually occurs in males under 25 years of age; may present as an
acute abdomen
• Sudden onset of severe, unilateral scrotal or inguinal pain
• Exquisitely tender and swollen testicle and spermatic cord; pain
worsened with elevation
• Leukocytosis and pyuria
• Technetium Tc 99m sodium pertechnetate scan shows decreased
uptake on the affected side (versus increased uptake with epididymitis)
• Doppler ultrasonography confirms diagnosis
• Differential Diagnosis
• Epididymitis
• Orchitis
• Testicular trauma
• Testicular tumor
• Treatment
• Inability to rule out testicular torsion requires surgical consult
• Diagnostic confirmation requires immediate surgery
• Pearl
Probably the diagnosis least easily forgotten by the affected patient in
all ofmedicine.
Reference
Galejs LE: Diagnosis and treatment of the acute scrotum. Am Fam Physician
1999;59:817. [PMTD: 10068706]
Chapter 11 Genitourinary & Renal Disorders 287
+
Benign Prostatic Hyperplasia
• Essentials of Diagnosis
• Urinary hesitancy, intermittent stream, straining to initiate micturition,
reduced force and caliber of the urinary stream, nocturia,
frequency, urgency
• Palpably enlarged prostate
• Hematuria, pyuria when infection complicates
• High postvoid residual volume as determined by ultrasonography
or excretory urography; not always prognostic of outcome
• May be complicated by acute urinary retention or azotemia following
prolonged obstruction
• Differential Diagnosis
• Urethral stricture
Vesicular stone
• Neurogenic bladder
• Prostate cancer
• Bladder tumor
• Treatment
• Treat associated infection if present; trimethoprim-sulfamethoxazole
is usually best
• Minimize evening fluid intake
• Alphaj-blockers for symptom relief; androgen suppression (finasteride)
in certain populations
Utilization of symptom scoring instruments to follow success of
treatment
• Transurethral resection for intolerable symptoms, refractory urinary
retention, recurrent gross hematuria, and progressive renal
insufficiency with demonstrated obstruction
• Pearl
In acute urinary retention in older men, ask about recent upper respiratOI)'
infections; anticholinergic medications in over-the-counter
remedies may be the answer.
Reference
Ramsey EW: Office treatment of benign prostatic hyperplasia. Urol C1in North
Am 1998;25:571. [pMID: 10026766]
288 Essentials of Diagnosis &Treatment
RENAL DISORDERS
Acute Renal Failure
• Essentials of Diagnosis
• When not otherwise qualified, usually synonymous with acute
tubular necrosis
• Anorexia with nausea, lethargy, headache, confusion
• History can include exposure to nephrotoxic agents, sepsis, trauma,
surgery, shock, or hemorrhage
• Oliguria in many patients
• Pericardial friction rub, asterixis may be present
• Azotemia with increased potassium and phosphate, decreased
serum bicarbonate
• Inability to retain sodium
• Kidneys of normal size or enlarged on imaging studies; renal
osteodystrophy absent
• Hematuria, proteinuria, and isosthenuria with renal tubular casts
• Differential Diagnosis
• Prerenal azotemia (eg, cirrhosis, nephrosis, heart failure, hypovolemia)
• Postrenal azotemia (eg, obstructive uropathy)
• Treatment
• Volume resuscitation with isotonic fluid for hypovolemia
• Ultrasonography to rule out obstructive process
• Possible renal biopsy (eg, if cause unknown or glomerulonephritis
suspected)
• Supportive care for uncomplicated cases: minimize fluid intake,
follow potassium and bicarbonate levels
• Oliguric renal failure with worse prognosis than a nonoliguric
process; role ofdiuretics to convert to latter process recommended
but unproved
• Dialysis for fluid overload, hyperkalemia, pericarditis, symptoms
of uremia
• Adjust dosage of medications for reduced glomerular filtration rate
• Pearl
If a contrast study is perfonned in acute renal failure (however inappropriately),
capture the first ~pecimen thereafter-it has the highest
yieldjor casts, which are diagnostic.
Reference
Agrawal M et al: Acute renal failure. Am Fam Physician 2000;61 :2077. [PMID:
10779250]
Chapter 11 Genitourinary & Renal Disorders 289
Chronic Renal Insufficiency
+
• Essentials of Diagnosis
• End stage of many glomerular or interstitial diseases
• Malaise, headaches, anorexia, nausea, hiccups, pruritus, occasional
polyuria and nocturia
• Hypertension, hyperpnea, pallor; signs of congestive heart failurecommon
Progressive azotemia over weeks to years
• Anemia, azotemia, and metabolic acidosis; hyperkalemia in oliguric
patients, hyperphosphatemia, hypocalcemia, isosthenuria;
benign urinary sediment with possible broad waxy casts
• Bilateral shrunken kidneys on imaging studies; exceptions include
polycystic kidney disease, diabetic nephropathy, myeloma kidney,
HIY-associated nephropathy
• Renal osteodystrophy
• Differential Diagnosis
• Obstructive uropathy
Acute renal failure
• Prerenal azotemia
• Drug toxicity
• Treatment
• Attention to comorbid factors, especially hypertension
Low-protein diet, salt and water restriction for patients with hypertension
and edema, multivitamin and folic acid supplements
Potassium, phosphorus, and magnesium restriction once GFR is
below approximately mLimin
Phosphorus binders for associated hyperphosphatemia with avoidance
of chronic aluminum hydroxide if possible; calcium and vitamin
D supplements if needed to prevent osteodystrophy; aim for
intact parathyroid hormone of two to three times normal values
Dialysis (peritoneal or hemodialysis) for end-stage renal disease
Renal transplantation for all eligible patients
• Pearl
Untreated chronic renal insufficiency is the cause of the highest PTH
levels in clinical medicine.
Reference
McCarthy JT: A practical approach to the management of patients with chronic
renal failure. Mayo Clin Proc 1999;74:269. [PMID: 10089997]
290 Essentials of Diagnosis &Treatment
Acute Glomerulonephritis
• Essentials of Diagnosis
• History of preceding streptococcal or other infection, evidence of
systemic vasculitis may be present
• Malaise, headache, fever, dark urine
• Hypertension, edema, and retinal hemorrhages typical
• Azotemia in all save mesangial nephropathy; moderate proteinuria,
low fractional excretion of sodium, and hematuria with or
without dysmorphic red cells and red cell casts
• Depending on the history, further tests may include complement
levels (CH50, C3, C4), antistreptolysin a (ASO) titer, antideoxyribonuclease
B (anti-DNA B) titer, antinuclear antibody (ANA)
titers, anti-GBM antibody levels, anti-neutrophil cytoplasmic
antibodies, hepatitis Band C antibodies, cryoglobulins, and renal
biopsy to establish cause
• Differential Diagnosis
• IgA nephropathy
• Goodpasture's syndrome (anti-GBM antibody syndrome)
• Other vasculitides (eg, polyarteritis nodosa, SLE)
• Membranoproliferative glomerulonephritis
• Hepatitis B- or C-associated glomerulonephritis, other postinfectious
glomerulonephritides
• Infective endocarditis
• Wegener's granulomatosis
• Henoch-Schonlein purpura
• Treatment
• Steroids and cytotoxic agents are used for rapidly progressive
glomerulonephritis, more effective at higher GFRs
• Plasmapheresis occasionally of value in anti-GEM disease
• Lower blood pressure slowly to prevent sudden decreases in renal
perfusion
• Supportive therapy with fluid and sodium restriction
• Monitor for malignant hypertension, congestive heart failure
• Pearl
A red cell cast indicates glomerulonephritis; a urine specimen after
1000 mL ofwater and an hour of lordosis increases the yield.
Reference
Couser WG: Glomerulonephritis. Lancet 1999;353:1509. (PMID: 99247293)
Chapter 11 Genitourinary & Renal Disorders 291
Nephrotic Syndrome
+
• Essentials of Diagnosis
• May be primary or secondary: systemic infections (such as secondary
syphilis, malaria, endocarditis), diabetes, multiple myeloma
with or without amyloidosis, heavy metals, and autoimmune
diseases
• Anorexia, dyspnea, anasarca, foamy urine
• Proteinuria (> 3.5 gI24h), hypoalbuminemia « 3 g/dL), edema,
hyperlipidemia in < 50% upon presentation
• Hypoalbuminemia may cause ascites, hydrothorax, anasarca, and
pulmonary edema, particularly when serum albumin < 2 g/dL
• Hypercoagulability with peripheral renal vein thrombosis
• Lipiduria with oval fat bodies, Maltese crosses, and fatty and
waxy casts in urinary sediment
• Depending on the history, further tests may include complement
levels (CH50, C3, C4), serum and urine electrophoresis, antinuclear
antibody (ANA), renal ultrasound, and renal biopsy if
treatment implications present
• Differential Diagnosis
• Congestive heart failure
• Cirrhosis
• Constrictive pericardi tis
• Hypothyroidism
• Treatment
• Supportive therapy with fluid and sodium restriction, lipidlowering
agents
• Low-protein diet (unless urinary protein loss exceeds 10 g/24 h;
then, additional dietary protein to match losses)
• When diabetes is present, consider ACE inhibitor even if renal
function is decreased
• Corticosteroids for minimal change disease (lipoid nephrosis); in
focal and segmental glomerular sclerosis, longer courses of steroid
therapy are beneficial; membranous nephropathy is best treated
with corticosteroids and cytotoxic agents; in membranoproliferative
glomerulonephropathy, steroid use is less well established
• Pearl
Unexplained membranous glomerulonephritis in patients over 50 suggests
a paraneoplastic response to a visceral malignancy.
Reference
Orth SR et aI: The nephrotic syndrome. N Engl J Med 1998;338:1202. [PMlD:
9554862]
292 Essentials of Diagnosis & Treatment
IgA Nephropathy (Berger's Disease)
• Essentials of Diagnosis
• Most common form of acute and chronic glomerulonephritis in
the USA and Asian countries
• Focal proliferative glomerulonephritis of unknown cause
• First episode: macroscopic hematuria, often associated with a
viral infection, with or without upper respiratory and gastrointestinal
symptoms
• Recurrent hematuria and mild proteinuria over decades, with same
precipitants
• Serum IgA increased in 30-50%; renal biopsy reveals inflammation
and deposition of IgA with or without C3 and IgM in the
mesangium of all glomeruli
• Usually indolent; 20-30% of patients progress to end-stage renal
disease over 2-3 decades
• Differential Diagnosis
• Poststreptococcal acute glomerulonephritis
• Infective endocarditis
• Goodpasture's syndrome
• Other vasculitides (eg, polyarteritis nodosa, SLE)
• Wegener's granulomatosis
• Henoch-Schonlein purpura
• Treatment
• Supportive therapy for patients with < 1 g/d of proteinuria with
yearly monitoring of renal function
• In patients with proteinuria> Ig/d, decrease with ACE inhibitors
• Fish oil of questionable benefit but not harmful
• Steroids in selected causes
• Pearl
Berger's disease is not Buerger's disease the latter is thromboangiitis
obliterans.
Reference
Julian BA: Treatment ofigA nephropathy. Semin NephroI2000;20:277. [PMlD:
10855937]
Chapter 11 Genitourinary & Renal Disorders 293
+
Anti-Glomerular Basement Membrane Nephritis
(Goodpasture's Syndrome)
• Essentials of Diagnosis
• Triad of pulmonary hemorrhage with hemoptysis, circulating
anti-GBM antibody, and glomemlonephritis due to anti-GBM
• Most common in young (18-30) and middle-aged (50-60s) white
men; smokers also have a predilection
• Extrarenal manifestations may be absent
• On immunofluorescence, renal biopsy reveals linear deposition
of IgG with or without C3 deposition along the glomerular basement
membrane
• Semm anti-GBM antibody is pathognomonic
• Differential Diagnosis
• Wegener's granulomatosis
• Other vasculitides (eg, polyarteritis nodosa, SLE)
• Endocarditis
• Postinfectious glomerulonephritis
• Primary pulmonary hemorrhage
• Treatment
• Plasmapheresis to remove circulating anti-GBM antibody
• Prednisone and cyclophosphamide for at least 3 months
• Recovery of renal function more likely if treatment is begun prior
to a serum creatinine of 6-7 mg/dL; hemodialysis as necessary
• Renal transplant delayed for 3-6 months after disappearance of
antibody from the serum
• Pearl
One ofthe few causes in medicine ofa dramatically elevated DLco.
Reference
Kalluri R: Goodpasture syndrome. Kidney Int 1999;55:1120. [PMID:
10027952]
294 Essentials of Diagnosis & Treatment
Acute &Chronic Tubulointerstitial Nephritis
• Essentials of Diagnosis
• Responsible for 10-15% of cases of acute renal failure
• Most drug-related (beta-Iactam antibiotics or NSAIDs), but may
be idiopathic or, rarely, associated with infections such as legionellosis
and leptospirosis
• Sudden decrease in renal function, associated with fever, maculopapular
rash, and eosinophilia; flank pain may be present
• Hematuria, pyuria, proteinuria, white blood cell casts, and occasionally
eosinophils in urine (Wright's stain necessary)
• Chronic tubulointerstitial nephritis characterized by polyuria and
nocturia, salt wasting, mild proteinuria, small kidneys, isosthenuria,
hyperchloremic metabolic acidosis
• Chronic form may result from prolonged obstruction, analgesic
abuse, sickle cell trait, chronic hypercalcemia, uric acid nephropathy,
or exposure to heavy metals
• Differential Diagnosis
• Acute or chronic glomerulonephritis
• Prerenal azotemia
• Primary obstructive uropathy
• Treatment
• Discontinue all possible offending drugs or treat associated infection
in patients with acute tubulointerstitial nephritis
• Corticosteroids of debatable benefit but often used if renal function
does not improve shortly after discontinuation of drug
• Temporary dialysis llUly be necessary in up to one-third of patients
with drug-induced acute interstitial nephritis
• Pearl
In ill-defined pain syndromes (headache, low back pain) with moderate
renal insufficiency, over-the-counter analgesics used to great excess by
the patient may be the culprit.
Reference
Rastegar A et al: The clinical spectrum of tubulointerstitial nephritis. Kidney Int
1998;54:313. [PMlD: 9690 I08]
Chapter 11 Genitourinary & Renal Disorders 295
Uric Acid Nephropathy
+
• Essentials of Diagnosis
• Three distinct syndromes; terminology confusing
• Uric acid nephrolithiasis: Radiolucent urate stones in 3% of patients
with gout
• Gouty kidney: interstitial sodium urate crystals of uncertain significance
in patients with gout and interstitial nephropathy; no
correlation with degree of elevation of serum uric acid
• Uric acid nephropathy: uric acid sludge within nephron due to
cellular necrosis, typically after chemotherapy, in patients without
previous gout
• Differential Diagnosis
• Renal failure due to other cause
Hypertensive nephrosclerosis
• Nephrolithiasis due to other cause
• Myeloma kidney
• Treatment
• Depends upon syndrome
Intravenous hydration and alkalinization of urine for uric acid
stones
Pretreatment with allopurinol and intravenous hydration for
selected patients receiving chemotherapy; maintain urine pH
> 6.5 and urine output> 2 Lid
In patients with gout, allopurinol and colchicine adjusted for renal
function; NSAID use minimized in patients with renal dysfunction
• Pearl
Remember aspirin and uric acid; at low dose « 3 g/d), aspirin causes
hyperuricemia because of blockage of secretion; at higher doses, all
transpoH is impaired and extreme hypouricemia ensues.
Reference
Reiter L et al: Familial hyperuricemic nephropathy. Am J Kidney Dis 1995;
25:235. [pMlD: 7847350]
296 Essentials of Diagnosis & Treatment
Obstructive Nephropathy
• Essentials of Diagnosis
• Most cases are postvesical and usually of prostatic origin
• A few cases result from bilateral ureteral obstruction, usually
from stones
• Postvesical obstruction presents with nocturia, incontinence, malaise,
nausea, with normal 24-hour urine output but in swings
Renal ultrasound localizes site of obstruction with proximal tract
dilation and hydronephrosis
• Spectrum of causes includes anatomic abnormalities, stricture,
tumor, prostatic hypertrophy, bilateral renal stones, drug effect
(methysergide), and neuromuscular disorders
• Differential Diagnosis
• Prerenal azotemia
• Interstitial nephritis
• Acute or chronic renal failure due to any cause
• Treatment
• Urinary catheter or ultrasonography to mle out obstmction secondary
to enlarged prostate
• Nephrostomy tubes if significant bilateral hydronephrosis present
with bilateral ureteral obstruction
• Treatment of concurrent infection if present
• Observe for postobstructive diuresis; can be brisk
• Pearl
One stone can cause obstructive nephropathy-in the one in 500
patients born with a single kidney.
Reference
Klahr S: Obstructive nephropathy. Intern Med 2000;39:355. [PMI D: 10830173]
Chapter 11 Genitourinary & Renal Disorders 297
Myeloma Kidney
+
• Essentials of Diagnosis
• May be initial presentation of multiple myeloma
• The systemic disease with easily the most renal and metabolic
compl ications
• Classic definition: Light chain of immunoglobulins (Bence Jones
proteins) directly toxic to tubules, or causing tubular obstruction
by precipitation
• Myeloma may also be associated with glomerular amyloidosis,
hypercalcemia, nephrocalcinosis, nephrolithiasis, plasma cell infiltration
of the renal parenchyma, hyperviscosity syndrome compromising
renal blood flow, proximal (Fanconi-like syndrome) or
distal renal tubular acidosis, type IV renal tubular acidosis, and
progressive renal insufficiency
• Serum anion gap is low in the majority due to positively charged
paraprotein
• Serum and urinary electrophoresis reveals monoclonal spike in
over 90% of patients; some cases are nonsecretory and are very
aggressive clinically
• Differential Diagnosis
• Interstitial nephritis
Prerenal azotemia
Obstructive nephropathy
• Nephrotic syndrome of other cause
• Drug-induced nephropathy
• Treatment
• Therapy for myeloma; prognosis for renal survival is better if
serum creatinine is < 2 mg/dL prior to treatment
• Treat hypertension and hypercalcemia if present
• Avoid contrast agents and other nephrotoxins
• Avoid dehydration and maintain adequate intravascular volume;
remember that hypercalcemia causes nephrogenic diabetes insipidus,
and trus worsens dehydration
• Pearl
The urine dipstick detects only albumin and intact globulin; light chains
are missed even when present in large amounts.
Reference
Goldschmidt H et al: Multiple myeloma and renal failure. Nephrol Dial Transplant
2000;15:301. [PMID: 10652511]
298 Essentials of Diagnosis & Treatment
Polycystic Kidney Disease
• Essentials of Diagnosis
• Autosomal dominant inheritance and nearly complete penetrance,
thus strikingly positive family history
• Abdominal or flank pain associated with hematuria, frequent urinary
tract infections, and positive family history
• Hypertension, large palpable kidneys, positive family history
• Renal insufficiency in 50% of patients by age 70; unlikely to develop
renal disease if no cystic renal lesions by age 30
• Normal hematocrits common: the cysts may elaborate erythropoietin
• Diagnosis confirmed by ultrasonography or CT scan
• Increased incidence of cerebral aneurysms (10% of affected patients),
aortic aneurysms, and abnormalities of the mitral valve;
40-50% have concomitant hepatic cysts
• Differential Diagnosis
• Renal cell carcinoma
• Simple renal cysts
• Other causes of chronic renal failure
• Treatment
• Treat hypertension and nephrolithiasis
• Observe for urinary tract infection
• Low-protein diet
• High fluid intake
• Patients with family history of cerebral aneurysm should have
screening abdominal CT
• Occasional nephrectomy required for repeated episodes of pain
and infection
• Excellent outcome with transplant
• Pearl
Hypertension, an abdominal mass, ana azotemia is polycystic disease
until proved otherwise.
Reference
Torres VE: New insights into polycystic kidney disease and its treatment. Curr
Opin Nephrol Hypertens 1998;7:159. [PMlD: 9529618]
Chapter 11 Genitourinary & Renal Disorders 299
Renal Tubular Acidosis
+
• Essentials of Diagnosis
• Unexplained metabolic acidosis with a normal anion gap
• Type I (distal): inability to acidify urine, hypokalemia, abnormal
(positive) urinary anion gap; may be familial (autosomal dominant)
or secondary to autoimmune disease, obstructive uropathy,
drugs (eg, amphotericin B), hyperglobulinemia, hypercalciuria,
or sickle cell anemia
• Type II (proximal): bicarbonaturia, glycosuria, hypokalemia,
aminoaciduria, phosphaturia, and uricosuria due to impaired
absorption; may be secondary to myeloma, drugs, or renal transplant
• Type IV: low renin and aldosterone; hyperkalemia, abnormal
(positive) urinary anion gap; typical of renal insufficiency; others
due to diabetes mellitus, drugs (eg, ACE inhibitors, NSAIDs,
cyclosporine), chronic interstitial nephritis, or nephrosclerosis
• Differential Diagnosis
• Fanconi's syndrome
• Diarrhea
• Ileal loop constriction after surgery for bladder cancer
• Hypokalemia or hyperkalemia from other causes
• Treatment
• Discontinue offending drug or treat underlying disease if present
• Bicarbonate or citrate and potassium replacement for types I and II
• Vitamin D analogs for type I to prevent osteomalacia, not type II
because of possible hypercalcemia and further damage to the distal
tubule
• Thiazides may increase bicarbonate reabsorption for type II
• Fludrocortisone for type IV only if volume repletion is difficult
• Pearl
Along with SIADH, type 1/ renal tubular acidosis is one of the few
causes ofhypouricemia in all ofmedicine.
Reference
Smulders YM et al: Renal tubular acidosis. Pathophysiology and diagnosis. Arch
Intern Med 1996;156:1629. [PMID: 8694660]
300 Essentials of Diagnosis & Treatment
Acute Cystitis & Pyelonephritis
• Essentials of Diagnosis
• Dysuria with urinary frequency and urgency, abdominal or flank
pain
• Fever, flank or suprapubic tenderness, and vomiting with pyelonephritis
• Pyuria, bacteriuria, hematuria, positive urine culture, white cell
casts on urinalysis (latter in pyelonephritis)
• Usually caused by gram-negative bacteria (eg, E coli, proteus,
klebsiella, Enterobacteriaceae) but may be due to gram-positive
organisms (eg, Enterococcus faecalis, Staphylococcus saprophyticus)
• Differential Diagnosis
Urethritis
• Nephrolithiasis
• Prostatitis
• Pelvic inflammatory disease or vaginosis
• Lower lobe pneumonia
• Surgical abdomen due to any cause, eg, appendicitis
• Treatment
• Empiric oral antibiotics (eg, trimethoprim-sulfamethoxazole,
cephalexin, or ciprofloxacin) for 3 days for uncomplicated cystitis
• Oral or intravenous antibiotics (eg, tluoroquinolone or cephalosporin)
for 7-14 days for pyelonephritis
• Intravenous antibiotics and fluids if dehydration or vomiting
present
Pyridium for early symptomatic relief
• Consider hospitalization for patients with single kidney or
immunosuppression
Pursue evaluation for anatomic ahnormalities in men who develop
cystitis or pyelonephritis
• Recurrent episodes of cystitis (more than two per year) often
treated with low-dose prophylactic antibiotics
• Pearl
Pyelonephritis is one ofthe reasons flO one should have an exploratory
laparotomy witlwut a urinalysis.
Reference
Roberts JA: Management of pyelonephritis and upper urinary tract infections.
Urol Clin North Am 1999;26:753. [PMJD: 10584616]
Chapter 11 Genitourinary & Renal Disorders 301
Asymptomatic Bacteriuria
+
• Essentials of Diagnosis
• History of recurring urinary tract infections may be present
• Bacteriuria with absence of symptoms or signs referable to the
urinary tract
• May be associated with obstruction, anatomic or neurologic abnormalities,
pregnancy, indwelling catheter, urologic procedures,
diverted urinary stream (eg, ileal loop conduit), diabetes, or old age
• Usually caused by Enterobacteriaceae, pseudomonas, or enteroCOCCI
• Differential Diagnosis
• Drug-induced nephropathy, especially analgesics
• Contaminated urine specimen
• Treatment
• Indications for treatment include pregnancy, persistent bacteriuria
in certain patients and prior to urologic procedures
Urine culture to guide antimicrobial therapy
• Surgical relief of obstruction if present
• In selected cases, chronic antibiotic suppression
• Pearl
Most patients with asymptomatic bacteriuria should not be given antibiotics.
Reference
Nicolle LE: Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am
1997; 11 :647. [PMID: 9378928]
302 Essentials of Diagnosis & Treatment
Lupus Nephritis
• Essentials of Diagnosis
• Can be the initial presentation of systemic lupus erythematosus
• WHO classification of renal biopsy: normal renal biopsy (class I);
mesangial proliferation (class Il); focal proliferation (class TIl);
diffuse proliferation (class IV); membranous (class V)
• Proteinuria or hematuria of glomerular origin; hypocomplementemic
common
• Glomerular filtration rate need not be depressed
• Chronic changes on biopsy portend a worse prognosis
• Differential Diagnosis
• Glomerulonephritis due to other diseases, including anti-GBM disease,
microscopic polyarteritis, Wegener's membranous nephropathy,
IgA nephropathy
• Nephrotic syndrome due to other causes
• Treatment
• Follow serial measures of renal function and urinalysis
• Strict control of hypertension
• ACE inhibitor to reduce proteinuria
• Steroids and cytotoxic agents for severe class III or any class IV
• Repeat biopsy for Rare of renal disease
• Upon reaching end-stage renal disease, renal transplantation is an
excellent alternative to dialysis
• Pearl
The kidney is not involved when SLE is drug-induced.
Reference
Mojcik CF et al: End-stage renal disease and systemic lupus erythematosus. Am
J Med 1996; 101: 100. [PMTD: 8686702]
Chapter 11 Genitourinary & Renal Disorders 303
+
Hypertensive Nephrosclerosis
• Essentials of Diagnosis
• Poorly controlled hypertension for over 15 years; alternatively,
severe, aggressive hypertension, especially in young blacks
• With extreme blood pressure elevation, papilledema and encephalopathy
may occur
• Ultrasound reveals bilateral small, echogenic kidneys
Proteinuria is usual
• Biopsy can show thickened vessels and sclerotic glomeruli; malignant
nephrosclerosis reveals characteristic onion-skinning
• Differential Diagnosis
• Atheroembolic or atherosclerotic renal disease
• Renal artery stenosis, especially bilateral
• End-stage renal disease due to any other cause
• Treatment
• Strict sodium restriction
• Aggressive control of hypertension, including ACE inhibitor if
possible
If patient presents with hypertensive urgency or emergency,
decrease blood pressure slowly over several days to prevent
decreased renal perfusion
May take up to 6 months of adequate blood pressure control to
achieve improved baseline of renal function
• Pearl
In benign nephrosclerosis, the rule is for serum creatinine to rise after
begimling therapy. Stay the course with blood pressure control and improved
renal function will follow.
Reference
Luke RG: Hypenensive nephrosclerosis: pathogenesis and prevalence. Essential
hypertension is an important cause of end-stage renal disease. Nephrol Dial
Transplant 199914:2271. [pMID: 10568241]
304 Essentials of Diagnosis & Treatment
Diabetic Nephropathy
• Essentials of Diagnosis
• Seen in diabetes mellitus of 15-20 years' duration
• Diabetic retinopathy almost always present
• GFR increases initially, returns to nonnal as further renal damage
occurs, then continues to fall
• Proteinuria> 1 g/d, often nephrotic range
• Normal to enlarged kidneys on ultrasound
• Biopsy can show mesangial matrix expansion, diffuse glomerulosclerosis
and nodular intercapillary glomerulosclerosis, the latter
pathognomonic
• Differential Diagnosis
• Nephrotic syndrome due to other cause, especially amyloidosis
• Glomerulonephritis with nephrotic features such as that seen in
systemic lupus erythematosus, membranous glomerulonephritis,
or IgA nephropathy
• Treatment
ACE inhibition or, probably, angiotensin n receptor blockade
early may reduce hyperfiltration
• Strict glycemic and blood pressure control
• Supportive care for progression of chronic renal insufficiencyincludes
treatment of anemia, avoidance of renal osteodystrophy
• Protein restriction has been advocated but not proved in clinical
trials
• Transplantation an alternative to dialysis at end stage, but comorbid
vasculopathy can be daunting
• Pearl
One ojmedicine'sjew causes ojmassive albuminuria sustained in the
end stages ojrenal junction.
Reference
Ritz E et al: Nephropathy in patients with type 2 diabetes mellitus. N Engl J Med
1999;341: 1127. [PMTD: 10511612]
12
Neurologic Diseases
Migraine Headache
• Essentials of Diagnosis
• Onset in adolescence or early adulthood
• Classic pattern: lateralized, unilateral throbbing pain, with prodrome
including nausea, photophobia, scotomas
• May be triggered by stress, foods (chocolate, red wine), birth control
pills
• Basilar artery variant: profound visual disturbances, dysequilibrium,
followed by occipital headache
• Ophthalmic variant: painless loss of vision, scotomas, usually
unilateral
• Differential Diagnosis
• Tension headache
• Cluster headache
• Giant cell arteritis
• Subarachnoid hemorrhage
• Mass lesion, eg, tumor or abscess
• Treatment
• Avoidance of precipitating factors
• Acute treatment: triptans, ergotamine with caffeine; analgesics
(preferably at onset of prodrome)
• Maintenance therapy includes NSAIDs, propranolol, amitriptyline,
ergotamine, valproic acid
• Pearl
Interesting etymology: hemi (mi) cranium (graine), a linguistic corruption
here indicating the unilaterality ofthe process.
Reference
Ferrari MD: Migraine. Lancet 1998;351:1043. [PMID: 9546526]
305
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
306 Essentials of Diagnosis &Treatment
Idiopathic Epilepsy
• Essentials of Diagnosis
• Abrupt onset of paroxysmal, transitory, recurrent alterations of
central nervous system function, often accompanied by alteration
in consciousness
• Family history may be present
• Generalized tonic-clonic (grand mal): loss of consciousness, generalized
motor convulsions; altered mentation or focal abnormalities
may persist for up to 48 hours postictally
Partial seizures: focal motor convulsions or altered consciousness
(complex); may become generalized
• Absence seizures may be manifested only as episodic inattention,
usually in children
• Characteristic EEG during seizures; often abnormal during interictal
periods
• Differential Diagnosis
• Seizures due to metabolic disorders (electrolyte disturbance),
toxins (alcohol, cocaine), or vascular, infectious, neoplastic, or
immunologic disease
• Syncope
• Narcolepsy
• Psychiatric abnormalities (hysteria, panic attack)
• Stroke (when patient first seen postictally)
• Hypoglycemia
• Treatment
• Phenytoin, carbamazepine, and valproic acid for most types of
epilepsy
• Newer generation anticonvulsants and phenobarbital may be helpful
in patients unresponsive to other medications
• For absence seizures, ethosuximide, valproic acid, and clonazepam
are useful
• Status epilepticus is treated as a medical emergency with intravenous
diazepam or lorazepam and phenytoin; general anesthesia
with barbiturates or halothane may be necessary in refractory cases
• Pearl
Remember subclinical epilepsy in critically ill and unconscious patients.
EEG may reveal status epilepticus.
Reference
Feely M: Fortnightly review: drug treatment of epilepsy. BMJ 1999; 318: 106.
[PMJD: 9880286]
Chapter 12 Neurologic Diseases 307
+ ..+
Ischemic & Hemorrhagic Stroke
• Essentials of Diagnosis
• May have history of atherosclerotic heart disease, hypertension,
diabetes, val vular heart disease, or atrial fibrillation
• Sudden onset of neurologic complaint, variably including focal
weakness, sensory abnormalities, visual change, language defect,
or altered mentation
• Neurologic signs dependent on vessels involved: hemiplegia,
hemianopia, and aphasia in anterior circulatory involvement; cranial
nerve abnormalities, quadriplegia, cerebellar findings in posterior
circulatory disease; hyperreflexia in both, but may be delayed
• Deficits persist> 24 hours; if resolution in < 24 hours, transient
ischemic attack or other process is present
• CT of the head may be normal in the first 24 hours, depending on
cause; hemorrhage visible immediately; MRI a superior imaging
modality in posterior fossa
• Differential Diagnosis
• Primary or metastatic brain tumor
• Subdural or epidural hematoma
• Brain abscess
• Multiple sclerosis
• Any metabolic abnormality, especially hypoglycemia
• Neurosyphilis
• Seizure (and postictal state)
• Migraine
• Treatment
• Control ofcontributing factors, especially hypenension and hypercholesterolemia
• Tissue plasminogen activator (t-PA) for selected patients with
ischemic stroke who can be treated within 3 hours after onset
• Anticoagulation for stroke due to cardiac emholi
• Aspirin, c1opidogrel, or the combination dipyridamole and aspirin
for thrombotic stroke
• Carotid endarterectomy may be considered later in selected patients
• Pearl
A stroke is never a stroke unless it's fwd 50 ofD50.
Reference
Brott T et al: Treatment of acute ischemic stroke. N Engl J Med 2000;343:710.
[pMID: 10974136]
308 Essentials of Diagnosis &Treatment
Intracranial Aneurysms & Subarachnoid Hemorrhage
• Essentials of Diagnosis
• Asymptomatic until expansion or rupture; sometimes preceded
by abrupt onset of headaches that resolve (sentinel leaks)
• Rupture characterized by sudden, severe headache, altered mental
status, photophobia, nuchal rigidity, and vomiting
• Focal neurologic signs unusual except for third nerve palsy with
posterior communicating artery aneurysm
• Multiple in 20% of cases; associated with polycystic renal disease,
coarctation of aorta, fibromuscular dysplasia
• CT scan or bloody cerebrospinal fluid confirmatory; MRl or MRA
may reveal aneurysm; cerebral angiography indicates size, location,
and number
• Differential Diagnosis
• Primary or metastatic intracranial tumor
• Hypertensive intraparenchymal hemorrhage
• Ruptured arteriovenous malformation
• Tension headache
• Migraine headache
• Meningitis
• Treatment
• Nimodipine (calcium channel blocker) may reduce neurologic
deficits
• fnduced hypertension and intracranial angioplasty may be useful
for treating vasospasm, which often accompanies subarachnoid
hemorrhage
• Definitive therapy with surgical clipping or endovascular coil
embolization of aneurysm if anatomy suitable and if patient's
functional status is otherwise acceptable
• Small unruptured aneurysms may not require treatment
• Pearl
When a patient complains of "the worst headache / ever had in my
life," it's a ruptured berry aneurysm.
Reference
&lIow JA et al: Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage.
N Engl J Med 2000;342:29. [PMID: 10620647]
Chapter 12 Neurologic Diseases 309
Arteriovenous Malformations
+ ..+
• Essentials of Diagnosis
• Congenital vascular malformations that consist of arteriovenous
communications without intervening capillaries
• Patients typically under age 30 and normotensive
• Initial symptoms include acute headache, seizures, abrupt onset
of coma-the latter with rupture
• May also present as transverse myelitis (spinal cord arteriovenous
malformation)
• Up to 70% of arteriovenous malformations bleed during their natural
history, most commonly before age 40
• CT of the brain suggests diagnosis; angiography characteristically
diagnostic, but some types (eg, cavernous malformations) may
not be visualized; MRI often helpful
• Differential Diagnosis
• Dural arteriovenous fistulas
• Seizures due to other causes
• Hypertensive intracerebral hemorrhage
• Ruptured intracranial aneurysm
• Intracranial tumor
• Meningitis or brain abscess
• Transverse myelopathy due to other causes
• Treatment
• Excision if malformation accessible and neurologic risk not great
• Endovascular embolization in selected malformations
• Radiosurgery for small malformations
• Pearl
The most common cause of intracranial hemorrhage between ages 15
and 30.
Reference
Arteriovenous malformations of the brain in adults. N Engl J Med 1999;
340: 1812. [PMlD: 10362826]
310 Essentials of Diagnosis &Treatment
Brain Abscess
• Essentials of Diagnosis
• History of sinusitis, otitis, endocarditis, chronic pulmonary infection,
or congenital heart defect common
• Headache, focal neurologic symptoms, seizures may occur
• Examination may confirm focal findings
• The most common organisms are streptococci, staphylococci,
and anaerobes; toxoplasma in AIDS patients; commonly polymicrobial
• Ring-enhancing lesion on CT scan or MRI; lumbar puncture
potentially dangerous because of mass effect
• Differential Diagnosis
• Primary or metastatic tumor
• Cerebral infarction
• Encephalitis
• Subdural empyema
• Neurosyphilis
• Treatment
• Intravenous broad-spectrum antibiotics (with coverage to include
anaerobic organisms) may be curative if abscess smaller than 2 cm
in diameter
• Surgical aspiration through burr hole if no response to antibiotic
drugs, either clinically or by CT scan
• Pearl
Frank brain abscess is the least common neurologic manifestation of
endocarditis.
Reference
Treatment of brain abscess. Lancet 1988; 1:219. [PMTD: 2893043]
Chapter 12 Neurologic Diseases 311
+ ..+
Pseudotumor Cerebri
(Benign Intracranial Hypertension)
• Essentials of Diagnosis
• Headache, diplopia, nausea
• Papilledema, sixth nerve palsy
• CT scan shows nonnal or small ventricular system
• Lumbar puncture with elevated pressure but normal cerebrospinal
fluid
• Associations include sinus thrombosis (transverse or sagittal),
endocrinopathy (hypoparathyroidism, Addison's disease), hypervitaminosis
A, drugs (tetracyclines, oral contraceptives), chronic
pulmonary disease, obesity; often idiopathic
• Untreated pseudotumor cerebri may lead to secondary optic atrophy
and permanent visual loss
• Differential Diagnosis
• Primary or metastatic tumor
• Optic neuritis
• Neurosyphilis
• Brain abscess or basilar meningitis
• Chronic meningitis (eg, coccidioidomycosis or cryptococcosis)
• Vascular headache, migraine headache
• Treatment
• Treat underlying cause if present
• Acetazolamide or furosemide to reduce cerebrospinal fluid formation
• Repeat lumbar puncture with removal of cerebrospinal fluid
• Oral corticosteroids may be helpful; weight loss in obese patients
• Surgical therapy with placement of ventriculoperitoneal shunt or
optic nerve sheath fenestration in refractory cases
• Pearl
Pseudotumor may not be "pseudo" in women-mammography may
indicate a primary breast cancer.
Reference
Radhakrishnan K et al: Idiopathic intracranial hypertension. Mayo Clinic Proc
1994;69: 169. [PMlD: 8309269]
312 Essentials of Diagnosis & Treatment
Parkinson's Disease
• Essentials of Diagnosis
• Insidious onset in older patient of pill-rolling tremor (3-5/s),
rigidity, bradykinesia, and progressive postural instability; tremor
is the least disabling feature
• Mask-like facies, cogwheeling of extremities on passive motion;
cutaneous seborrhea characteristic
Absence of tremor-not uncommon-may delay diagnosis
• Reflexes normal
• Mild intellectual deterioration often noted, but concurrent Alzheimer's
disease may account for this in many
• Differential Diagnosis
• Essential tremor
• Phenothiazine, metoclopramide toxicity; also carbon monoxide,
manganese poisoning
• Hypothyroidism
• Wilson's disease
• Multiple system atTophy, progressive supranuclear palsy
• Diffuse Lewy body disease
• Depression
• Normal pressure hydrocephalus
• Treatment
• Carbidopa-levodopa is most effective medical regimen in patients
with definite disability; dose should be reduced if dystonias occur
• Dopamine agonists and bromocriptine may be of value as firstline
therapy or in permitting reduction of carbidopa-levodopa
dose
• Anticholinergic drugs and amantadine are useful adjuncts
Inhibition of monoamine oxidase B with selegiline (L-deprenyl)
offers theoretical advantage of preventing progression but not yet
estahlished for this indication
Surgical options remain highly controversial
• Pearl
Autonomic abnormalities early in the course of a parkinsonian syndrome
mean the diagnosis is not Parkinson's disease.
Reference
Young R: Update on Parkinson's disease. Am Fam Physician 1999;59:2155.
[PMJD: J0221302]
Chapter 12 Neurologic Diseases 313
Huntington's Disease
• Essentials of Diagnosis
• Family history usually present (autosomal dominant)
• Onset at age 30-50, with gradual progressive chorea and dementia;
death usually occurs within 20 years after onset
• Caused by a trinucleotide-repeat expansion in a gene located on
the short arm of chromosome 4
• The earliest mental changes are often behavioral, including hypersexuality
• CT scan shows cerebral atTophy, particularly in the caudate
• Differential Diagnosis
• Sydenham's chorea
• Tardive dyskinesia
• Lacunar infarcts of subthalamic nuclei
• Other causes of dementia
• Treatment
• Principally supportive
• Antidopaminergic agents (eg, haloperidol) or reserpine may reduce
severity of movement abnormality
• Genetic counseling for offspring
• Pearl
All movement abnormalities in Huntington's disease disappear when
the patient is asleep.
Reference
Ross CA et al: Huntington disease and the related disorder, dentatorubralpallidoluysian
atrophy (DRPLA). Medicine 1997;76:305. [pMID: 9352736]
..
314 Essentials of Diagnosis &Treatment
Tourette's Syndrome
• Essentials of Diagnosis
• Motor and phonic tics; onset in childhood or adolescence
• Compulsive utterances, often of obscenities, are typical
• Hyperactivity, nonspecific electroencephalographic abnormalities
in 50%
• Obsessive-compulsive disorder common
• Differential Diagnosis
• Simple tic disorder I
• Wilson's disease
• Focal seizures
• Treatment
• Haloperidol is the drug of choice
• Clonazepam, clonidine, phenothiazine, pimozide if intolerant of
or resistant to haloperidol
• Serotonin-specific reuptake inhibitors for obsessive-compulsive
symptoms
• Pearl
When a child has no neurologic signs other than tics and Wilson's disease
has been excluded, think Tourette's syndrome.
Reference
8agheri MM et al: Recognition and management of Tourette's syndrome and tic
disorders. Am Fam Physician 1999;59:2263. [PMlD: 10221310]
Chapter 12 Neurologic Diseases 315
Multiple Sclerosis
+
• Essentials of Diagnosis
• Patient usually under 50 years of age at onset
• Episodic symptoms that may include sensory abnormalities,
blurred vision due to optic neuritis, sphincter disturbances, and
weakness with or without spasticity
• Neurologic progression to fixed abnormalities occurs variably
• Single pathologic lesion cannot explain clinical findings
• Multiple foci in white matter best demonstrated radiographically
byMRT
• Finding of oligoclonal bands or elevated Ig index on lumbar puncture
is nonspeci fic
• Differential Diagnosis
• Vasculitis or systemic lupus erythematosus
• Small-vessel infarctions
• Neurosyphilis
• Optic neuritis due to other causes
• Primary or metastatic central nervous system neoplasm
• Cerebellar ataxia due to other causes Pernicious anemia
Spinal cord compression or radiculopathy due to mechanical com- __ pression
Syringomyelia
• Treatment
• Beta-interferon reduces exacerbation rate; copolymer I (a random
polymer-simulating myelin basic protein) may also be beneficial
• Steroids may hasten recovery from relapse
• Treatment with other immunosuppressants may be effective, but
role is controversial
• Symptomatic treatment of spasticity and bladder dysfunction
• Pearl
If you diagnose multiple sclerosis in a patient over age 50, diagnose
something else.
Reference
Noseworthy JH et al: Multiple sclerosis. N Engl J Medicine 2000;343:
938. [PMID: 11006371]
316 Essentials of Diagnosis &Treatment
Syringomyelia
• Essentials of Diagnosis
• Characterized by destruction or degeneration of the gray and whi te
matter adjacent to the central canal of the cervical spinal cord
• Initial loss of pain and temperature sense with preservation of
other sensory function; unrecognized burning or injury of hands
a characteristic presentation
• Weakness, hyporeflexia or areflexia, atrophy of muscles at level
of spinal cord involvement (usually upper limbs and hands);
hyperreflexia and spasticity at lower levels
• Thoracic kyphoscoliosis common; associated with Arnold-Chiari
malformation
• Secondary to trauma in some cases
• MRI confirms diagnosis
• Differential Diagnosis
• Spinal cord tumor or arteriovenous malformation
• Transverse myelitis
• Multiple sclerosis
• Neurosyphilis
• Degenerative arthritis of the cervical spine
• Treatment
• Surgical decompression of the foramen magnum
• Syringostomy in selected cases
• Pearl
One of the few causes of disassociation of pain and temperature on
neurologic examination.
Reference
Schwartz ED et al: Posttraumatic syringomyelia: pathogenesis, imaging, and
treatment. AJR Am J Roentgenol 1999;173:487. [PMID: 104301591
Chapter 12 Neurologic Diseases 317
• + Treatment ..+
Guillain-Barre Syndrome
(Acute Inflammatory Polyneuropathy)
• Essentials of Diagnosis
• Associated with viral infections, stress, and preceding Campylobacter
jejuni enteritis, but most cases do not have any definite
link to pathogens
• Progressive, usually ascending, symmetric weakness with variable
paresthesia or dysesthesia; autonomic involvement (eg, cardiac
irregularities, hypertension, or hypotension) may be prominent
• Electromyography consistent with demyelinating injury; also a
less common axonal form
• Lumbar puncture, normal in early or mild disease, shows high
protein, normal cell count later in course
• Differential Diagnosis
• Diphtheria, poliomyelitis (where endemic)
• Porphyria
• Heavy metal poisoning
• Botulism
• Transverse myelitis of any origin
• Familial periodic paralysis
• Plasmapheresis or intravenous immunoglobulin
• Pulmonary functions closely monitored, with intubation of forced
vital capacity < 15 mL/kg
• Respiratory toilet with physical therapy
• Up to 20% of patients are left with persisting disability
• Pearl
The occasional Guillain-Barre may start in the stem and descend-the
C. Miller Fischer variant.
Reference
Hahn AF: Guillain-Barre syndrome. Lancet 1998;352:635. [PMID: 9746040]
318 Essentials of Diagnosis & Treatment
Bell's Palsy (Idiopathic Facial Paresis)
• Essentials of Diagnosis
• An idiopathic facial paresis
• Abrupt onset of hemifacial (including the forehead) weakness,
difficulty closing eye; ipsilateral ear pain may precede or accompany
weakness
• Unilateral peripheral seventh nerve palsy on examination; taste
lost on the anterior two-thirds of the tongue, and hyperacusis may
occur
• Differential Diagnosis
• Carotid distribution stroke
• Intracranial mass lesion
• Basilar meningitis, especially that associated with sarcoidosis
• Treatment
• Treatment with corticosteroids and acyclovir when it can be initiated
early
• Supportive measures with frequent eye lubrication and nocturnal
eye patching
• Only 10% of patients are dissatisfied with the final outcome of
their disability or disfigurement
• Pearl
The Bell phelwmenon: the eye on the affected side moves superiorly and
laterally when the patient closes his eyes.
Reference
Jackson CG et al: The facial nerve. Current trends in diagnosis, treatment, and
rehabilitation. Med Clin North Am 1999;83: 179. [PMID: 9927969]
Chapter 12 Neurologic Diseases 319
Combined System Disease
(Posterolateral Sclerosis)
• Vitamin BI2
• + Treatment ..+
• Essentials of Diagnosis
• Numbness (pins and needles), tenderness, weakness; feeling of
heaviness in toes, feet, fingers, and hands
• Stocking and glove distribution of sensory loss in some patients
• Extensor plantar response and hyperreflexia typical, as is loss of
position and vibratory senses
• Serum vitamin BI2 level low
• Megaloblastic anemia may be present but does not parallel neurologic
dysfunction
• Differential Diagnosis
• Tabes dorsalis
• Multiple sclerosis
• Transverse myelitis of viral or other origin
• Epidural tumor or abscess
• Cervical spondylosis
• Polyneuropathy due to toxin or metabolic abnormality
• Pearl
When BI2 deficiency is the cause, pharmacologic amounts offolic acid
may worsen the neurologic picture.
Reference
Clementz GL et al: The spectrum of vitamin 8" deficiency. Am Pam Physician
1990;4 J: J50. [PMTD: 2278553]
320 Essentials of Diagnosis & Treatment
Myasthenia Gravis
• Essentials of Diagnosis
• Symptoms due to a variable degree of block of neuromuscular
transmission
• Fluctuating weakness of most-commonly used muscles; diplopia,
dysphagia, ptosis, facial weakness with chewing and speaking
• Short-acting anticholinesterases transiently increase strength
Electromyography and nerve conduction studies demonstrate
decremental muscle response to repeated stimuli
• Associations include thymic tumors, thyrotoxicosis, rheumatoid
arthritis, and SLE
Elevated acetylcholine receptor antibody assay confirmatory but
not completely sensitive
• Differential Diagnosis
• Botulism
• Lambert-Eaton syndrome
• Polyneuropathy due to other causes
• Amyotrophic lateral sclerosis
• Bulbar poliomyelitis
• Neuromuscular blocking drug toxicity (aminoglycosides)
Primary myopathy, eg, polymyositis
• Treatment
• Anticholinesterase drugs-particularly pyridostigmine-may be
effective
• Thymectomy in an otherwise healthy patient under age 60 if
weakness not restricted to extraocular muscles
• Corticosteroids and immunosuppressants if response to above
measures not ideal
Plasmapheresis or intravenous immunoglobulin therapy provides
short-term benefit in selected patients
Avoid aminoglycosides
• Many other medications may lead to exacerbations
• Pearl
Given the day-to-day variability ofsymptoms, many patients are labeled
with a psychiatric diagnosis before myasthenia gravis is considered, let
alone diagnosed.
Reference
Keesey J: Myasthenia gravis. Arch Neural 1998;55:745. [PMID: 9605737]
Chapter 12 Neurologic Diseases 321
+
Periodic Paralysis Syndromes
• Essentials of Diagnosis
• Episodes of flaccid weakness or paralysis with strength normal
between attacks
• Hypokalemic variety: attacks may be prolonged upon awakening,
after exercise or after carbohydrate meals; hyperthyroidism commonly
associated in Asian men
• Hyperkalemic variety or normokalemic variety: brief attacks after
exercise
• Differential Diagnosis
• Myasthenia gravis
• Polyneuropathies due to other causes, especially GuiUain-Barre
syndrome
• Treatment
• Hypokalemic variant: potassium replacement for acute episode;
low-carbohydrate, low-salt diet chronically, perhaps acetazolamide
prophylactically; treatment of hyperthyroidism, when
associated, reduces attacks, as does therapy with beta-blockers • Hyperkalemic-normokalemic variant: intravenous calcium, intra- __ venous diuretics useful for acute therapy; prophylactic acetazol- amide or thiazides also beneficial
• Pearl
Potassiwn levels as low as can be observed in medicine, yet commonly
rise spontaneously before treatment is given.
Reference
Griggs RC et al: Mutations of sodium channels in periodic paralysis: can they
explain the disease and predict treatment? Neurology 1999:52: 1309. [PMID:
10227611]
322 Essentials of Diagnosis & Treatment
Trigeminal Neuralgia (Tic Douloureux)
• Essentials of Diagnosis
• Characterized by momentary episodes of lancinating facial pain
that arises from one side of the mouth and shoots toward the ipsilateral
eye, ear, or nostril
• Commonly affects women more than men in mid and later life
• Triggered by touch, movement, and eating
• Symptoms are confined to the distribution of the ipsilateral trigeminal
nerve (usually the second or third division)
• Occasionally caused by multiple sclerosis or a brain stem tumor
• Differential Diagnosis
• Atypical facial pain syndrome
• Glossopharyngeal neuralgia
• Postherpetic neuralgia
• Temporomandibular joint dysfunction
• Angina pectoris
• Giant cell arteritis
• Brain stem gliosis
• Treatment
• Either carbamazepine or gabapentin is the drug of choice; if this
is ineffective or poorly tolerated, phenytoin, valproic acid, or
baclofen can be tried
• Surgical exploration of posterior fossa successful in selected
patients
• Radiofrequency ablation useful in some
• Pearl
The diagnosis can sometimes be made before the patient says a word:
a man unshaven unilaterally in the V2 distribution has tic douloureux
until proved otherwise.
Reference
Kumar GK et al: When is facial pain trigeminal neuralgia? Postgrad Med
1998;104:149. [PMlD: 9793561]
Chapter 12 Neurologic Diseases 323
+
Normal Pressure Hydrocephalus
• Essentials of Diagnosis
• Subacute loss of higher cognitive function
• Urinary incontinence
• Gait apraxia
• In some, history of head trauma or meningitis
• Normal opening pressure on lumbar puncture
• Enlarged ventricles without atrophy by CT or MRI
• Differential Diagnosis
• Dementia or incontinence due to other cause
• Parkinson's disease
• Alcoholic cerebellar degeneration
• Wernicke-Korsakoff syndrome
• Encephalitis
• Treatment
• Lumbar puncture provides temporary amelioration of symptoms
• Ventriculoperitoneal shunting, most effective when precipitating
event is identified and recent
• Pearl
An apraxic gait differsfrom an ataxic gait--thefonner is magnetic, as
though the floor were a magnet and the patient had shoes with metal
soles.
Reference
Vanneste JA: Diagnosis and management of normal-pressure hydrocephalus.
J NeuroI2000;247:5. [PMJD: 10701891]
..-
13
Geria'lric Disorders
Dementia
• Essentials of Diagnosis
• Persistent and progressive impairment in intellectual function,
including loss of short-term memory, word-finding difficulties,
apraxia (inability to perform previously learned tasks), agnosia
(inability to recognize objects), and visuospatial problems (becoming
lost in familiar surroundings)
• Behavioral disturbances, psychiatric symptoms common
• Alzheimer's disease accounts for roughly two-thirds of cases;
vascular dementia causes most others
• Differential Diagnosis
• Normal age-related cognitive changes or drug effects
• Delirium, depression, or other psychiatric disorder
• Metabolic disorder (eg, hypercalcemia, hyper- and hypothyroidism,
or vitamin B12 deficiency)
• Tertiary syphilis
• Normal-pressure hydrocephalus, subdural hematoma
• Parkinson's disease
• Dementia associated with less common disorders, such as Pick's
disease, Creutzfeldt-Jakob disease, or AIDS
• Treatment
• Correct sensory deficits, treat underlying disease, remove offending
medications, and treat depression, when present
• Caregiver education, referral to Alzheimer Association, advance
care planning early
• Consider anticholinesterase inhibitor, such as donepezil
• Treat behavioral problems (eg, agitation) with behavioral interventions
or medications directed against target symptom
• Pearl
Vitamin B12 deficiency can cause reversible dementia without hematologic
abnormalities.
Reference
Patterson CJ et al: The recognition, assessment and management of dementing
disorders: conclusions from the Canadian Consensus Conference on Dementia.
CMAJ 1999;160(12Suppl):Sl. [pMID: 10410645]
324
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 13 Geriatric Disorders 325
Delirium
+
• Essentials of Diagnosis
• Rapid onset of acute confusional state, usually lasting less than
I week
• Fluctuating mental status with marked deficit of short-term memory
• Inability to concentrate, maintain attention, or sustain purposeful
behavior
• Increased anxiety and irritability
Risk factors include dementia, organic brain lesion, alcohol
dependence, medications, and various medical problems
• Mild to moderate delirium at night, often precipitated by hospitalization,
drugs, or sensory deprivation ("sundowning")
• Differential Diagnosis
• Depression or other psychiatric disorder
• Medical condition, such as hypoxemia, hypercalcemia, hyponatremia,
infection, thiamin deficiency
• Subarachnoid hemorrhage
• Medication side effect
Subclinical status epilepticus
• Pain
• Treatment
• Identify and treat underlying cause
• Promote restful sleep; keep patient up and interactive during day
Frequent reorientation by staff, family, clocks, calendars
• When medication needed, low-dose haloperidol or atypical antipsychotic,
avoid benzodiazepines except in alcohol and benzodiazepine
withdrawal
• Avoid potentially offending medications, particularly anticholinergic
and psychoactive medications
Avoid restraints, lines, and tuhes
• Pearl
Delirium tremens is the rrwstflagrant example but also the least common.
Reference
Chan D et al: Delirium: making the diagnosis, improving the prognosis. Geriatrics
1999;54:28. [PMlD: 10086025]
+
326 Essentials of Diagnosis & Treatment
Constipation
• Essentials of Diagnosis
• Infrequent stools (less than three times a week)
• Straining with defecation more than 25% of the time
• Differential Diagnosis
• Normal bowel function that does not match patient expectations
of bowel function
• Anorectal dysfunction
• Slow bowel transit
• Dietary factors, including low-calorie diet
• Obstructing cancer
• Metabolic disorder, such as hypercalcemia
• Medications (opioids, iron, calcium channel blockers)
• Treatment
• In absence of pathology, increase fiber and liquid intake
• In presence of slow transit constipation, stool softeners such as
docusate, osmotically active agents such as sorbitol and lactulose
• In refractory cases or with opioid use, stimulant laxatives (eg,
senna) may be necessary
• In presence of anorectal dysfunction, suppositories often necessary
• Pearl E One patient's constipation is another's diarrhea.
Reference
Schaefer DC et al: Constipation in the elderly. Am Fam Physician 1998;
58:907. [PMID: 9767726]
Chapter 13 Geriatric Disorders 327
Hearing Impairment
+
• Essentials of Diagnosis
• Difficulty understanding speech, difficulty listening to television
or talking on the telephone, tinnitus, hearing loss limiting personal
or social life
• "Whisper test": patient is unable to repeat numbers whispered in
each ear
• Hearing loss on formal audiologic evaluation (pure tone audiometry,
speech reception threshold, bone conduction testing, acoustic
reAexes, and tympanometry); hearing loss of>40 dB will cause
difficulty understanding normal speech
• Differential Diagnosis
• Sensorineural hearing loss (presbycusis, ototoxicity due to medications,
tumors or infections of cranial nerve VIII, injury by vascular
events)
• Conductive hearing loss (cerumen impaction, otosclerosis,
chronic otitis media, Meniere's disease, trauma, tumors)
• Treatment
• Cerumen removal if impaction present (Debrox, gentle irrigation
with warm water)
• Consider assistive listening devices (telephone amplifiers, lowfrequency
doorbells, closed-captioned television decoders) and
hearing aids
• Educate family to speak slowly and to face the patient directly
when speaking
• Pearl
Impaired hearing and vision may result in pseudodementia due to contraction
ofthe older patient's environment.
Reference
Fook Let al: Hearing impairment in older people: a review. Postgrad Med J
2000;76:537. [PMlD: 10964114]
+
328 Essentials of Diagnosis & Treatment
Decubitus Ulcers (Pressure Sores)
• Essentials of Diagnosis
• Ulcers over bony or cartilaginous prominences (sacrum, hips,
heels)
• Stage I (nonblanchable erythema of intact skin); stage n (partial
thickness skin loss involving the epidennis or dermis); stage 1lI
(full-thickness skin loss extending to the deep fascia); stage IV
(full-thickness skin loss involving muscle or bone)
• Risk factors: immobility, incontinence, malnutrition, cognitive
impairment, older age
• Differential Diagnosis
• Herpes simplex virus ulcers
• Venous insufficiency ulcers
Underlying osteomyelitis
• Ulcerated skin cancer
• Pyoderma gangrenosum
• Treatment
• Reduce pressure (reposition patient every 2 hours, use specialized
mattress)
• Treat underlying conditions that may prevent wound healing
(infection, malnutrition, poor functional status, incontinence,
comorbid illnesses)
• Control pain
• Select dressing to keep the wound moist and the surrounding tissue
intact (hydrocolloids, silver sulfadiazine, or, ifheavy exudate,
calcium alginate or foams)
Perform debridement if necrotic tissue present (wet-to-dry dressings,
sharp debridement with scalpel, collagenase, or moistureretentive
dressings)
• Surgical procedures may be necessary to treat extensive pressure
ulcers
• Pearl
There is no "early" decubitus; pathogenesis begins from within, and
skin loss is the last part ofthe process.
Reference
Cervo FA et al: Pressure ulcers. Analysis of guidelines for treatment and management.
Geriatrics 2000;55:55. [PMlD: 10732005]
Chapter 13 Geriatric Disorders 329
Weight Loss (Involuntary)
+
• Essentials of Diagnosis
• Weight loss exceeding 5% in 1 month or 10% in 6 months
• Weight should be measured regularly and compared with previous
measures and normative data for age and gender
• The cause of weight loss is usually diagnosed by history and physical
examination
• Most useful tests for further evaluation: chest x-ray, complete blood
count, serum chemistries (including glucose, thyroid-stimulating
hormone, creatinine, calcium, liver function tests, albumin), urinalysis,
and fecal occult blood testing
• Differential Diagnosis
• Medical disorders (congestive heart fai lure, chronic lung disease,
chronic renal failure, peptic ulcers, dementia, ill-fitting dentures,
dysphagia, malignancy, diabetes mellitus, hyperthyroidism, malabsorption,
systemic infections, hospitalization)
• Social problems (poverty, isolation, inability to shop or prepare
food, alcoholism, abuse and neglect, poor knowledge of nutrition,
food restrictions)
Psychiatric disorders (depression, schizophrenia, bereavement,
anorexia nervosa, bulimia)
Drug effects (serotonin reuptake inhibitors, NSAIDs, digoxin,
antibiotics)
• Treatment
• Directed at underlying cause of weight loss, which is usually multifactorial
Frequent meals, hand-feed, protein-calorie supplements
• Among patients with psychosocial causes of malnutrition, referral
to community services such as senior centers
• "Watchful waiting" when cause is unknown after basic evaluation
(2.')% of cases)
• Consider enteral tube feedings if treatment would improve quality
of life, remembering the importance of identifying goals of care
before instituting feedings
• Pearl
Pay attention to the definition: gradual weight loss over many years is
the rule in older patients, and aggressive evaluation may be harmful.
Reference
Gazewood JD et al: Diagnosis and management of weight loss in the elderly.
J Fam Pract 1998;47: 19. [pMID: 9673603]
+
330 Essentials of Diagnosis & Treatment
Falls
• Essentials of Diagnosis
• Frequently not mentioned to physicians
• Evidence of trauma or fractures, but this may be subtle, especially
in the hip
• Decreased activity, social isolation, or functional decline due to
fear of falling or as a result of it
• Differential Diagnosis
• Visual impairment
• Gait impairment due to muscular weakness, podiatric disorder, or
neurologic dysfunction
• Environmental hazards such as poor lighting, stairways, rugs,
warped Aoors
• Polypharmacy (especially with use of sedative-hypnotics)
• Postural hypotension
• Presyncope, vertigo, dysequilibrium, and syncope
• Treatment
• Review need for and encourage proper use of assistive devices
(eg, cane, walker)
• Evaluate and treat for osteoporosis
• Evaluate vision
• Review medications
• Assess home and environmental safety and prescribe modifications
as indicated
• Pearl
The occasional older person crawls into bed after afall causing a hip
fracture and stays there, and presents with altered mental status only;
lookfor shortening and external rotation ofthe hips in all older patients
with new-onset dementia.
Reference
Fuller GF: Falls in the elderly. Am Fam Physician 2000;61:2159. [PMID:
10779256]
Chapter 13 Geriatric Disorders 331
Polypharmacy
+
• Essentials of Diagnosis
• Risk factors: older age, cognitive impairment, taking five or more
medications, multiple prescribing physicians, and recent discharge
from a hospital
• A medical regimen that includes at least one unnecessary or inappropriate
medication, such that the likelihood of adverse effects
(from the number or type of medications) exceeds the likelihood
of benefit
Medications used to prevent ill ness without improving symptoms
have increasingly marginal risk-benefit profiles in patients with
limited life expectancies
• Over-the-counter drugs and vitamin supplements often added on
by patient without physician's awareness
• Differential Diagnosis
• Appropriate use of multiple medications to treat older adults for
multiple comorbid conditions
• Treatment
• Regularly review all medications, instructions, and indications
Keep dosing regimens as simple as possible
• Avoid managing an adverse drug reaction with another drug
Select medications that can treat more than one problem
• Pearl
For any new symptom in an older patient, consider medications first.
Reference
Monane M et al: Optimal medication use in elders. Key to successful aging.
West J Med 1997; 167:233. [PMID: 9348752]
+
332 Essentials of Diagnosis & Treatment
Insomnia
• Essentials of Diagnosis
• Difficulty in initiating or maintaining sleep, or nonrestorative sleep
that causes impairment of social or occupational functioning
• For acute insomnia « 3 weeks), presence of recent Iife stress or
new medications
• May be related to a psychiatric disorder, such as major depression
or posttraumatic stress disorder
• Differential Diagnosis
• Psychiatric illness (depression, anxiety, mania, psychoses, stress,
panic attacks)
• Drug effect (caffeine, theophylline, serotonin reuptake inhibitors,
diuretics, others); withdrawal from sedative-hypnotic medications
or alcohol
• Comorbid disease causing chronic pain, dyspnea, urinary frequency,
reflux esophagitis, or delirium
• Akathisia
• Noisy environment, excessive daytime napping
• Disordered circadian rhythms (jet lag, shift work, dementia)
• Treatment
• Treat underlying cause of insomnia by removing or modifying
mitigating factors
• Maintain good sleep hygiene (avoid stimulants, minimize noise,
keep regular sleep schedule, avoid daytime naps, exercise regularly)
Refer for polysomnography if primary sleep disorder is suspected
• Consider short-term « 4 weeks) intermittent use of trazodone or
a sedative-hypnotic (eg, zolpidem or a benzodiazepine with shorthalf-
life)
• Diphenhydramine best avoided because of its anticholinergic side
effects
• Pearl
The need for sleep diminishes with age, though patients may perceive
a needfor 8 hours ofsleep throughout life.
Reference
Insomnia: assessment and management in primary care. National Heart, Lung,
and Blood Institute Working Group on Insomnia. Am Fam Physician
1999;59:3029. [PMTD: 10392587]
14
Psychiatric Disorders
Panic Disorder
• Essentials of Diagnosis
• Sudden, recurrent, unexpected panic attacks
• Characterized by palpitations, tachycardia, sensation of dyspnea
or choking, chest pain or discomfort, nausea, dizziness, diaphoresis,
numbness, depersonalization
• Sense of doom; fear of losing control or of dying
Persistent worry about future attacks
• Change in behavior due to anxiety about being in places where
an attack might occur (agoraphobia)
• Differential Diagnosis
• Endocrinopathies (eg, hyperthyroidism)
• Cardiac illness (eg, supraventricular tachycardia, myocardial
infarction)
Pulmonary illness (eg, chronic obstructive pulmonary disease,
asthma)
Pheochromocytoma
Medication or substance use or withdrawal
• Other anxiety disorders (eg, generalized anxiety disorder, posttraumatic
stress disorder)
• Major depressive disorder
• Somatoform disorders
• Treatment
• Cognitive-behavioral therapy
• Antidepressant medication (selective serotonin reuptake inhibitors,
tricyclic antidepressants, monoamine oxidase inhibitors)
• Benzodiazepines as adjunctive treatment
• May have only a single attack; reassurance, education thus important
early
• Pearl
In younger patients with multiple emergency room visits for cardiac
complaints and negative evaluations, panic attack is the most common
diagnosis.
Reference
Saeed SA et al: Panic disorder: effective treatment options. Am Fam Physician
1998;57:2405. [PMID: 9614411]
333
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
+
334 Essentials of Diagnosis &Treatment
Generalized Anxiety Disorder
• Essentials of Diagnosis
• Excessive, persistent worry
• Worry is difficult to control
• Physiologic symptoms of restlessness, fatigue, initabil ity, muscle
tension, sleep disturbance
• Differential Diagnosis
• Endocrinopathies (eg, hyperthyroidism)
• Pheochromocytoma
• Medication or substance use (eg, caffeine, nicotine, amphetamine,
pseudoephedrine)
• Medication or substance withdrawal (eg, alcohol, benzodiazepines)
• Major depressive disorder
• Adjustment disorder
• Other anxiety disorders (eg, obsessive-compulsive disorder)
• Somatoform disorders
• Personality disorders (eg, avoidant, dependent, obsessivecompulsive)
• Treatment
• Psychotherapy, especially cognitive-behavioral
• Relaxation techniques (eg, biofeedback)
• Buspirone, extended-release venlafaxine, benzodiazepines
• Pearl
In patients with anxiety and depression, treat the depression first.
Reference
Rickels K et al: The clinical presentation of generalized anxiety in primarycare
sellings: practical concepts of classification and management. J Clin
Pathol 1997;58(Suppl 11 ):4. [PMID: 9363042]
Chapter 14 Psychiatric Disorders 335
Stress Disorders
+
• Essentials of Diagnosis
• Includes acute stress disorder and posttraumatic stress disorder
• Exposure to a traumatic event
• Intrusive thoughts, nightmares, Aashbacks
• Mental distress or physiologic symptoms (eg, tachycardia, diaphoresis)
when exposed to stimuli that cue the trauma
• Avoidance of thoughts, feelings, or situations associated with the
trauma
Isolation, detachment from others, emotional numbness
• Sleep disturbance, irritability, hypervigilance, startle response,
poor concentration
• High comorbidity with depression and substance abuse
• Differential Diagnosis
• Other anxiety disorders (eg, panic disorder, generalized anxiety
disorder)
• Major depressive disorder
Adjustment disorder
• Psychotic disorders
Substance use or withdrawal
• Neurologic syndrome secondary to head trauma
• Treatment
• Individual and group psychotherapy
• Cognitive-behavioral therapy
• Antidepressant medication (selective serotonin reuptake inhibitors,
tricyclic antidepressants, phenelzine)
• Pearl
Consider this diagnosis in any patient with mood symptoms and a history
oftrauma such as rape, combat, or physical or sexual abuse.
Reference
Peebles-Kleiger MJ et al: Office management of posttraumatic stress disorder.
A clinician's guide Lo a pervasive problem. Postgrad Med 1998; 103(5): 1813,187-
8,194-6. (UI: 98253219)
+
336 Essentials of Diagnosis &Treatment
Phobic Disorders
• Essentials of Diagnosis
• Includes specific and social phobias
• Persistent, irrational fear due to the presence or anticipation of an
object or situation
• Exposure to the phobic object or situation results in excessive
anxiety
• Avoidance of phobic object or situation
• Social phobia: fear of humiliation or embarrassment in a performance
or social situation (eg, speaking or eating in public)
• Differential Diagnosis
• Other anxiety disorders (eg, generalized anxiety disorder, panic
disorder, posttraumatic stress disorder)
• Psychotic disorders
• Treatment
• Behavioral therapy (eg, exposure)
• Hypnosis
• Benzodiazepines as necessary for anticipated situations that
cannot be avoided (eg, flying)
• Beta-blockers for anticipated, circumscribed social phobia
(performance anxiety)
• Paroxetine for social phobia
• Pearl
The most common anxiety disorder, especially for public speaking.
Reference
den Boer JA: Social phobia: epidemiology, recognition, and treatment. BMJ
1997;315:796. [PMTD: 9345175]
Chapter 14 Psychiatric Disorders 337
+
Obsessive-Compulsive Disorder
• Essentials of Diagnosis
• Obsessions: recurrent, distressing, intrusive thoughts
• Compulsions: repetitive behaviors (eg, hand washing, checking)
that patient cannot resist performing
• Patient recognizes obsessions and compulsions as excessive
• Obsessions and compulsions cause distress and interfere with
functioning
• Differential Diagnosis
• Psychotic disorders
• Other anxiety disorders
• Major depressive disorder
• Somatoform disorders
• Obsessive-compulsive personality disorder: lifelong pattern of
preoccupation with orderliness and perfectionism but without
presence of true obsessions or compulsions
• Substance intoxication
• Tic disorder (eg, Tourette's syndrome)
• Treatment
• Behavioral therapy (eg, exposure, response prevention)
• Selective serotonin reuptake inhibitors or clomipramine
• Pearl
Lack ofinsight makes a diagnosis ofpsychotic disorder more likely.
Reference
Khouzam HR: Obsessive-compulsive disorder. What to do if you recognize
baffling behavior. Postgrad Med 1999;106: 133. [PMID: 10608970]
+
338 Essentials of Diagnosis &Treatment
Somatoform Disorders (Psychosomatic Disorders)
• Essentials of Diagnosis
• Includes conversion, somatization, pain disorder with psychologic
factors, hypochondriasis, and body dysmorphic disorder
• Symptoms may involve one or more organ systems and are unintentional
• Subjective complaints exceed objective findings
• Symptom development may correlate with psychosocial stress,
and symptoms are real to the patient
• Differential Diagnosis
• Major depressive disorder
• Anxiety disorders (eg, generalized anxiety disorder)
• Factitious disorder
• Malingering
• Organic disease producing symptoms
• Treatment
• Attention to building therapeutic relationship between patient and
a single primary provider
• Acknowledgment that patient's distress is real
• Avoidance of confrontation regarding reality of the symptoms
• Follow-up visits at regular intervals
• Focus on functioning and empathy regarding patient's psychosocial
difficulties
• Continued vigilance about organic disease
• Psychotherapy, especially group cognitive-behavioral
• Biofeedback; hypnosis
• Pearl
Table 14-1. Somatoform disorders
Sympwm prudllctiun
Unconscious Conscious
Motivation
Unconscious
Conscious
Somatoform disorders
(Not applicable)
Factitious disorders
Malingering
Reference
Righter EL et al: Managing somatic preoccupation. Am Fam Physician 1999;
59:31 J3. [PM1D: J0392593]
Chapter 14 Psychiatric Disorders 339
Factitious Disorder
+
• Essentials of Diagnosis
• Also known as Munchausen syndrome
• Intentional production or feigning of symptoms
• Motivation for symptoms is unconscious, to assume the sick role
• External incentives for symptom production are absent
• Patient may produce symptoms in another person in order to indirectly
assume the sick role (Munchausen by proxy)
• High correlation with personality disorders
• Differential Diagnosis
• Somatoform disorders
• Malingering
• Organic disease producing symptoms
• Treatment
• Gentle confrontation regarding diagnosis
• Emphasis on patient's strengths
• Empathy with patient's long history of suffering
Attention to building therapeutic relationship between patient and
a single primary provider
• Psychotherapy
• Many with less severe forms eventually stop or decrease selfdestructive
behaviors upon confrontation
• Pearl
When an obscure disorder eluding diagnosis develops in a patient recently
enrolled in studies in the medical field, afactitious etiology is high
on the list-ifnot at the top.
Reference
Wise MG et al: Factitious disorders. Prim Care 1999;26:3 J 5. [PMTD: J03J 8750]
+
340 Essentials of Diagnosis & Treatment
Personality Disorders
• Three Clusters
1. Odd, eccentric: paranoid, schizoid; schizotypal personality disorders
2. Dramatic: borderline, histrionic, narcissistic; antisocial personality
disorders
3. Anxious, fearful: avoidant, dependent; obsessive-compulsive
personality disorders
• Essentials of Diagnosis
• History dating from childhood or adolescence of recurrent maladaptive
behavior
• Minimal introspective ability
• Major recurrent difficulties with interpersonal relationships
• Enduring pattern of behavior stable over time, deviating markedly
from cultural expectations
• Increased risk of major depressive disorder
• Differential Diagnosis
Anxiety disorders
Dissociative disorders
• Major depressive disorder
• Bipolar disorder
• Psychotic disorders
• Substance use or withdrawal
Personality change due to medical illness (eg, central nervous
system neoplasm, stroke)
• Treatment
• Maintenance ofa highly structured environment and clear, consistent
interactions with the patient
• Individual or group therapy (eg, cognitive-behavioral, interpersonal)
• Antipsychotic medications may be required transiently in times
of stress or decompensation
• Serotonergic medications if depression or anxiety is prominent
• Serotonergic medications or mood stabilizers if emotionallabiIity
is prominent
• Pearl
One ofthe most challenging therapeutic problems in all ofmedicine.
Reference
Ohossche OM et al: Assessment and importance of personality disorders in medical
patients: an update. South Med J 1999;92:546. [PMID: 10372846]
Chapter 14 Psychiatric Disorders 341
Psychotic Disorders
+
• Essentials of Diagnosis
• Includes schizophrenia, schizoaffective and schizophreniform disorders,
delusional disorder, brief psychotic disorder, and shared
psychotic disorder
• Loss of ego boundaries, gross impairment in reality testing
• Prominent delusions or auditory hallucinations
• May have flat or inappropriate affect and disorganized speech,
thought processes, or behavior
• Brief psychotic disorder: symptoms last less than I month, then
resolve completely
• Differential Diagnosis
• Major depressive or manic episode with psychotic features
• Medication or substance use (eg, steroids, levodopa, cocaine,
amphetamines)
• Heavy metal toxicity
• Psychotic symptoms associated with dementia
• Delirium
• Complex partial seizures
• Central nervous system neoplasm
• Multiple sclerosis
Systemic lupus erythematosus
Endocrinopathies (eg, hypothyroidism, Cushing's syndrome)
• Infectious disease (eg, neurosyphilis)
• Nutritional deficiency (eg, thiamin, vitamin 8 12 )
• Acute intermittent porphyria
• Personality disorders (eg, paranoid, schizoid, schizotypal)
• Treatment
• Antipsychotic medications: atypical agents (risperidone, olanzapine,
quetiapine, c1ozapine) less likely to cause extrapyramidal
symptoms
Attempt to stabilize living situation and provide structured environment
• Psychotherapy may be effective for brief psychotic disorder after
episode resol ves
Behavioral therapy (eg, skills training)
• Pearl
The presence ofhalluciniltions or delusions means psychosis-whether
organic or functional in origin is determined next.
Reference
McGrath J et al: Fortnightly review. Treatment of schizophrenia. BMJ 1999;
319: 1045. [PMJD: 1052] 199]
+
342 Essentials of Diagnosis &Treatment
Major Depressive Disorder
• Essentials of Diagnosis
• Depressed mood or anhedonia (loss of interest or pleasure in
usual activities), with hopelessness, intense feelings of sadness
• Poor concentration, thoughts of suicide, worthlessness, guilt
• Symptoms include sleep or appetite disturbance (increased or decreased),
malaise, psychomotor retardation or agitation
Increased isolation and social withdrawal, decreased libido
• May have psychotic component (eg, self-deprecatory auditory
hallucinations), or multiple somatic complaints
• Symptoms last longer than 2 weeks and impair functioning
• Differential Diagnosis
• Bipolar disorder; adjustment disorder
• Dysthymic disorder: presence of some depressive symptoms for
at Ieast 2 years
• Bereavement
• Substance abuse (eg, alcohol) or withdrawal (eg, cocaine, amphetamine)
• Medication use (eg, steroids, interferon, reserpine)
• Medical illness (eg, hypothyroidism, stroke, Parkinson's disease,
neoplasm, polymyalgia rheumatica)
• Delirium or dementia
• Anxiety disorders (eg, generalized anxiety disorder, posttraumatic
stress disorder)
• Personality disorders
• Treatment
• Assess suicidal risk in all patients
• Antidepressant medications: selective serotonin reuptake inhibitors,
tricyclic antidepressants, venlafaxine, nefazodone, bupropion,
mirtazapine, monoamine oxidase inhibitors
• Psychotherapy (eg, cognitive-behavioral, interpersonal)
Interventions to help with resocialization (eg, supportive groups,
day treatment programs)
• Education of patient and family about depression
• Electroconvulsive therapy for refractory cases
• Antipsychotic medication if psychotic component present
• Pearl
Ask about history ofmania before starting an antidepressant; bipolar
patients may develop a manic episode when treated with an antidepressant.
Reference
Doris A et aI: Depressive illness. Lancet 1999;354: 1369. [PMID: 10533878]
Chapter 14 Psychiatric Disorders 343
Bipolar Disorder
+
• Essentials of Diagnosis
• History of manic episode: grandiosity, decreased need for sleep,
pressured speech, racing thoughts, distractibility, increased activity,
excessive spending or hypersexuality
• Depressive episodes may alternate with periods of mania
• Manic episode may have psychotic component
• Differential Diagnosis
• Substance intoxication (eg, cocaine, amphetamine, alcohol)
• Medication use (eg, steroids, thyroxine, methylphenidate)
• Infectious disease (eg, neurosyphilis, complications of H1V
infection)
• Endocrinopathies (eg, hyperthyroidism, Cushing's syndrome)
• Central nervous system neoplasm
• Complex partial seizures
• Personality disorders (eg, borderline, narcissistic)
• Treatment
• Mood stabilizer: lithium, valproic acid, carbamazepine
Antipsychotic medication (eg, olanzapine) for acute mania or psychotic
component
Psychotherapy may be helpful once acute mania is controlled
• Pearl
Inexperienced clinicians seeing their first manic patient invariably
diagnose hyperthyroidism.
Reference
Griswold KS et al: Management of bipolar disorder. Am Fam Physician
2000;62:1343. [PMTD: 11011863]
+
344 Essentials of Diagnosis & Treatment
Alcohol Dependence
• Essentials of Diagnosis
• Intoxication: somnolence, slurred speech, ataxia, nystagmus,
impaired attention or memory, coma
• Physiologic dependence with symptoms of withdrawal when intake
is intemlpted
• Tolerance to the effects of alcohol
• Presence of alcohol-associated medical illnesses (eg, liver disease,
cerebellar degeneration)
• Recurrent use resulting in multiple legal problems, hazardous situations,
or failure to fulfill role obligations
• Continued drinking despite strong medical and social contraindications
and life disruptions
• High comorbidity with depression
• Differential Diagnosis
• Alcohol use secondary to underlying major psychiatric illness
• Other sedative-hypnotic dependence or intoxication (eg, benzodiazepines)
• Intoxication by other substances or medications (eg, opioids)
• Withdrawal from other substances (eg, cocaine, amphetamine)
• Pathophysiologic disturbance such as hypoxia, hypoglycemia,
stroke, central nervous system infection, or subdural hematoma
• Treatment
• Total abstinence, not "controlled drinking," should be the goal
• Substance abuse counseling and groups (eg, Alcoholics Anonymous)
• Disulfiram in selected patients; naltrexone may also be of benefit,
in conjunction with substance abuse counseling
• Treat underlying depression if present
• Pearl
Mood or anxiety disorders are difficult to diagnose when a patient is
actively drinking.
Reference
O'Connor PG et al: Patients with alcohol problems. N Engl J Medicine 1998;
338:592. [PMTD: 9475768]
Chapter 14 Psychiatric Disorders 345
Alcohol Withdrawal
+
• Essentials of Diagnosis
• Symptoms when patient with dependence abruptly stops drinking
• Autonomic hyperactivity, tremor, wakefulness, psychomotor agitation,
anxiety, seizures, hallucinations or delusions
• Life-threatening severe withdrawal with disorientation and frightening
hallucinations (delirium tremens)
• Differential Diagnosis
• Delirium secondary to other medical illness (eg, infection, hypoglycemia,
hepatic disease)
• Withdrawal from other sedative-hypnotics (eg, benzodiazepines)
or opioids
• Substance intoxication (eg, cocaine, amphetamine)
• Anxiety disorders
• Manic episode
• Seizure disorder
• Treatment
• Renzodiazepines, with target of keeping vital signs normal
• Haloperidol if hallucinations are present
• Thiamin, folate, and multivitamins
• Encourage hydration
• Pearl
The longer the period between discontinuation ofalcohol and the appearance
ofsymptoms, the worse the delirium tremens.
Reference
Hall Wet al: The alcohol withdrawal syndrome. Lancet 1997;349: 1897 [PMID:
971770].
+
346 Essentials of Diagnosis &Treatment
Opioid Dependence &Withdrawal
• Essentials of Diagnosis
• Intoxication: somnolence, slurred speech, ataxia, coma, respiratory
depression, miotic pupils
• Physical dependence with tolerance
• Continued use despite disruptions in social and occupational
functioning
• Withdrawal: nausea, vomiting, abdominal cramps, lacrimation,
rhinorrhea, dilated pupils, dysphoria, irritability, diaphoresis,
insomnia, tachycardia, fever
• Withdrawal uncomfortable but not life-threatening
• Differential Diagnosis
• Alcohol or other sedative-hypnotic intoxication, dependence, or
withdrawal
• Intoxication by or withdrawal from other substances or medications
• Medical illness while intoxicated: hypoxia, hypoglycemia, stroke,
central nervous system infection or hemorrhage: during withdrawal:
other gastrointestinal or infectious disease
• Treatment
• Naloxone for suspected overdose with close medical observation
• Methadone maintenance after withdrawal for selected patients
• Clonidine may be helpful in alleviating the autonomic symptoms
of withdrawal
• Methadone may be used to treat acute withdrawal but only under
specific federal guidelines
• Substance abuse counseling and groups (eg, Narcotics Anonymous)
• Pearl
Many opioids are prescribed in fixed-drug combinations with agents
such as acetaminophen, which may have differing or additional toxicities.
Reference
Effective medical treatment of opiate addiction. National Consensus Development
Panel on Effective Medical Treatment of Opiate Addiction. JAMA
1998;280:1936. [PMID: 9851480]
Chapter 14 Psychiatric Disorders 347
Sexual Dysfunctions
+
• Essentials of Diagnosis
• Includes hypoactive sexual arousal disorder, sexual aversion disorder,
female sexual arousal disorder, male erectile disorder,
orgasmic disorder, premature ejaculation
• Persistent disturbance in the phases of the sexual response cycle
(eg, absence of desire, arousal, or orgasm)
• Causes significant distress or interpersonal difficulty
• Conditioning may cause or exacerbate dysfunction
• Differential Diagnosis
• Underlying medical condition (eg, chronic illness, various hormone
deficiencies, diabetes mellitus, hypertension, peripheral
vascular disease, pelvic pathology)
• Medication (eg, selective serotonin reuptake inhibitors, numerous
antihypertensives) or substance use (eg, alcohol)
• Depression
• Treatment
• Encourage increased communication with sexual partner
• Decrease performance anxiety via sensate focus, relaxation exercises
Sex or couples therapy, especially if life or relationship stressors
are present
Estrogen replacement in women or testosterone replacement in
men if levels are low
• Erectile dysfunction in men: consider vacuum device, alprostadil,
penile injection or implant, sildenafil
• Premature ejaculation: selective serotonin reuptake inhibitors may
help
• Pearl
Sexual dysfunction is often undiagnosed in women; relevam inquiries
should be made if there are ill-defined and poorly explained somatic
symptoms.
Reference
Morgentaler A: Male impotence. Lancet 1999;354:1713. [PMID: 9551480]
+
348 Essentials of Diagnosis & Treatment
Eating Disorders
• Essentials of Diagnosis
• Includes anorexia nervosa and bulimia nervosa
• Severe abnormalities in eating behavior
• Disturbance in perception of body shape or weight
• Anorexia: refusal to maintain a minimally normal body weight
• Bulimia: repeated binge eating, followed by compensatory behavior
to prevent weight gain (eg, vomiting, use of laxatives, excessive
exercise, fasting)
• Medical sequelae include gastrointestinal disturbances, electrolyte
imbalance, cardiovascular abnormalities, amenorrhea or oligomenorrhea,
caries or periodontitis
• Differential Diagnosis
• Major depressive disorder
Body dysmorphic disorder: excessive preoccupation with an
imagined defect in appearance
• Obsessive-compulsive disorder
• Weight loss secondary to medical illness (eg, neoplasm, gastrointestinal
disease, hyperthyroidism, diabetes)
• Treatment
• Psychotherapy (eg, cognitive-behavioral, interpersonal)
• Family therapy, particularly for adolescent patients
• Selective serotonin reuptake inhibitors (eg, ftuoxetine) may be of
benefit
• Medical management of associated physical sequelae
• Consider inpatient or partial hospitalization for severe cases
• Pearl
If bulimia is suspected, examine the knuckles, teeth, and perioral skin
for signs of self-induced vomiting.
Reference
Becker AE et aI: Eating disorders. N Engl J Medicine 1999;340:1092. (PMID:
10194240]
15
Dermatologic Disorders
Atopic Dermatitis (Atopic Eczema)
• Essentials of Diagnosis
• Pruritic, exudative, or lichenified eruption on face, neck, upper
trunk, wrists, hands, antecubital and popliteal folds
• Involves face and extensor surfaces more typically in infants
• Personal or family history of allergies or asthma
• Recurring; remission possible in adolescence
• Peripheral eosinophilia, increased serum IgE-not needed for
diagnosis
• Differential Diagnosis
• Seborrheic dermatitis
• Contact dermatitis
• Scabies
• Impetigo
• Eczema herpeticum may be superimposed on atopic dermatitis.
• Eczematous dermatitis may be presenting feature of immunodeficiency
syndromes in infants
• Treatment
• Avoidance of anything that dries or irritates skin
• Frequent emollients
• Topical corticosteroids
• Topical tacrolimus (FKS06) dramatically beneficial in severe
atopic dermatitis
• Phototherapy sometimes helpful
• Sedative antihistamines relieve pruritus
• Atopic patients frequently colonized with staphylococci; systemic
antibiotics helpful in flares
• Systemic steroids or cyclosporine only in highly selected cases
• Dietary restrictions may be of benefit in limited cases when specific
food allergies are implicated
• Pearl
While RAST testing is useful to exclude food allergies, positive results
correlate poorly with food challenges and are difficult to interpret.
Reference
Rothe MJ et aI: Atopic dennatitis: An update. J Am Acad Dennatol1996;35:1.
[PMTD: 96272959]
349
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
350 Essentials of Diagnosis & Treatment
Nummular Eczema
• Essentials of Diagnosis
• Middle-aged and older men most frequently affected
• Discrete coin-shaped, crusted, erythematous, 1-5 em plaques that
may contain vesicles
• Usually begins on lower legs, dorsal hands, or extensor surfaces
of arms but may spread
• Pruritus often severe
• Differential Diagnosis
• Tinea corporis
• Psoriasis
• Xerotic dermatitis
• Impetigo
• Contact dermatitis
• Treatment
• Avoidance of agents capable of drying or irritating skin (hot or
frequent baths, extensive soaping, etc)
• Frequent emollients
• Topical corticosteroids (potency appropriate to location and severity)
applied twice daily and tapered as tolerated
• Topical tar preparations
• Phototherapy may be helpful in severe cases
• Sedative antihistamines to relieve pruritus, given at bedtime
• Antibiotics when signs of impetiginization are present (fissures,
crusts, erosions, or pustules)
• Systemic steroids in highly selected, refractory cases
• Pearl
If it scales, scrape it-KOH preparation should always be examined to
rule out tinea corporis.
Reference
Rietschel RL et al: Nonatopic eczemas. J Am Acad Dermatol 1988;18:569.
[PMJD: 88170171]
Chapter 15 Dermatologic Disorders 351
Seborrheic Dermatitis &Dandruff
+
• Essentials of Diagnosis
• Loose, dry, moist, or greasy scales with or without underlying
crusted, pink or yellow-brown plaques
• Predilection for scalp, eyebrows, eyelids, nasolabial creases, lips,
ears, presternal area, axillae, umbilicus, groin, and gluteal crease
• Infantile form on scalp known as cradle cap
• Differential Diagnosis
• Psoriasis
Impetigo
• Atopic dermatitis
• Contact dermatitis
• Pityriasis rosea
• Tinea versicolor
• Pediculosis capitis (head lice)
• Treatment
• Selenium sulfide, tar, zinc, or ketoconazole shampoos
• Topical corticosteroids
• Topical ketoconazole cream
• Systemic corticosteroids and antibiotics in selected generalized
or severe cases
• Patient should be aware that chronic therapy is required to suppress
this condition
• Pearl
New-onset severe seborrheic dermatitis can occur in patients with Parkinson
's disease and with HIV infection.
Reference
Hay RJ et aJ: Dandruff and seborrheic dermatitis: Causes and management. Clin
Exp Dermatol 1997;22:3. [pMID: 97471102] -
+
352 Essentials of Diagnosis &Treatment
Allergic Contact Dermatitis
• Essentials of Diagnosis
• Erythema, edema, and vesicles in an area of contact with suspected
agent
• Weeping, crusting, or secondary infection may follow
• Intense pruritus
• Pattern of eruption may be diagnostic (eg, linear streaked vesicles
in poison oak or ivy)
• History of previous reaction to suspected contactant
Patch testing usually positive
• Common allergens include nickel, plants, neomycin, topical anesthetics,
fragrances, preservatives, hair dyes, textile dyes, nail care
products, adhesives, and constituents of rubber and latex products
• Differential Diagnosis
• Nonallergenic contact dermatitis
• Scabies
• Impetigo
• Dermatophytid reaction
• Atopic dermatitis
• Seborrheic dermatitis
• Treatment
• Identify and avoid contactant
• Topical corticosteroids for localized involvement
• Wet compresses with aluminum acetate solutions for weeping
lesions
• Oral corticosteroids for acute, severe cases; tapering may require
2-3 weeks to avoid rebound
• Pearl
Ifthe agent can be aerosolized, as with Rhus (poison oak and ivy), noncardiogenic
pulmonary edema may result eg, a campfire burning Rhus
branches.
Reference
Belsito DV: The diagnostic evaluation, treatment, and prevention of allergic contact
dennatitis in the new millennium. J Allergy C1in Immunol 2000;105:409.
[pMTD: 107 J9287]
Chapter 15 Dermatologic Disorders 353
Pityriasis Rosea
+
• Essentials of Diagnosis
• Oval, salmon-colored, symmetric papules with long axis following
cleavage lines
• Lesions show "collarette of scale" at periphery
• Trunk most frequently involved; sun-exposed areas often spared
• A "herald" patch precedes eruption by 1-2 weeks; some patients
report prodrome of constitutional symptoms
• Pruritus common but usually mild
• Variations in mode of onset, morphology, distribution, and course
are common
• Attempts to isolate infective agent have been disappointing
• Differential Diagnosis
• Secondary syphilis
• Tinea corporis
• Seborrheic dermatitis
• Tinea versicolor
• Viral exanthem
• Drug eruption
• Psoriasis
• Treatment
• Usually none required; most cases resolve spontaneously in
3-10 weeks
• Topical steroids or oral antihistamines for pruritus
• UVB phototherapy may expedite involution of lesions
• Short course of systemic corticosteroids in selected severe cases
• Pearl
As in all similar rashes: RPR.
Reference
Allen RA et al: Pityriasis rosea. Cutis 1995;56:198. [PMID: 96127440]
+
354 Essentials of Diagnosis & Treatment
Psoriasis
• Essentials of Diagnosis
• Silvery scales on bright red, well-demarcated plaques on knees,
elbows, and scalp
• Pitted nails or onychodystrophy
• Pinking of intergluteal folds
• Pruritus mild or absent
Associated with psoriatic arthritis
• Lesions may be induced at sites of injury (Koebner phenomenon)
• Many variants
• Differential Diagnosis
• Cutaneous candidiasis
• Tinea corporis
• Nummular eczema
• Seborrheic dermatitis
• Pityriasis rosea
• Secondary syphilis
• Pityriasis rubra pilaris
• Nail findings may mimic onychomycosis
• Cutaneous features of reactive arthritis may mimic psoriasis
• Plaque stage of cutaneous T cell lymphoma may mimic psoriasis
• Treatment
• Topical steroids, calcipotriene, tar preparations, anthralin, salicylic
acid, or tazarotene
• Tar shampoos, topical steroids, calcipotriene, keratolytic agents,
or intralesional steroids for scalp lesions
• Phototherapy (UYB, psoralen plus UYA, or the Goeckerman regimen)
for widespread disease
• Systemic steroids not used because of risk of severe rebound or
induction of pustular psoriasis
• In selected severe cases, systemic methotTexate, cyclosporine, or
acitretin
• Pearl
Look carefully at the nails under magnification. Pitting may be subtle
but can clinch the diagnosis.
Reference
Stem RS: Psoriasis. Lancet 1997;350:349. [PMJD: 9251649]
Chapter 15 Dermatologic Disorders 355
Exfoliative Dermatitis (Erythroderma)
+
• Essentials of Diagnosis
• Erythema and scaling over most of the body
• Itching, malaise, fever, chills, lymphadenopathy, weight loss
• Preexisting dermatosis causes more than half of cases
• Skin biopsy to identify cause
• Leukocyte gene rearrangement studies if Sezary syndrome suspected
and biopsies nondiagnostic
• Differential Diagnosis
• Erythrodermic psoriasis
• Pityriasis rubra pilaris
• Drug eruption
• Atopic dermatitis
• Contact dermatitis
• Severe seborrheic dermatitis
• Sezary syndrome of cutaneous T cell lymphoma
• Hodgkin's disease
• Treatment
• Soaks and emollients
• Midpotency topical steroids, possibly under occlusive suit
• Hospitalization may be required
• Specific systemic therapies
• Discontinue offending agent in drug-induced cases
• Antibiotics for secondary bacterial infections
• Pearl
Unexplained erythrodenna in a middle-aged person raises the index of
suspicion for a visceral malignancy.
Reference
Rothe MJ et aI: Erythroderma. Dermatol Clin 2000;18:405. [PMID: 10943536]
+
356 Essentials of Diagnosis & Treatment
Cutaneous TCell Lymphoma (Mycosis Fungoides)
• Essentials of Diagnosis
• Early stage: erythematous 1- to 5-cm patches, sometimes pruritic,
on lower abdomen, buttocks, upper thighs, and, in women, breasts
• Middle stages: infiltrated, erythematous, scaly plaques
• Advanced stages: skin tumors, erythroderma, lymphadenopathy,
or visceral involvement
• Skin biopsy critical; serial biopsies may be required to confirm
diagnosis
• CD4/CD8 ratios, tests to detect clonal rearrangement of the T cell
receptor gene
• Differential Diagnosis
• Psoriasis
• Drug eruption
• Eczematous dennatoses
• Leprosy
• Tinea corporis
• Other lymphoreticular malignancies
• Treatment
• Treatment depends on stage of disease
• Early and aggressive therapy may control cutaneous lesions-not
shown to prevent progression
• High-potency corticosteroids, mechlorethamine, or carmustine
(BCNU) topically
• Phototherapy (psoralen plus UVA) in early stages
• Total skin electron beam radiation, photophoresis, systemic chemotherapy,
retinoids, and alpha interferon for advanced disease
• Denileukin diftitox (DAB389IL-2; diphtheria toxin fused to recombinant
IL-2)
• Pearl
Early stage disease usually progresses slowly, and many patients die of
other causes.
Reference
Lorincz AL: Cutaneous T cell lymphoma (mycosis fungoides). Lancet 1996;
347:871. [PMTD: 8622396]
Chapter 15 Dermatologic Disorders 357
lichen Planus
+
• Essentials of Diagnosis
• Small pruritic, violaceous, polygonal, flat-topped papules; may
show white streaks (Wickham's striae) on surface
• On flexor wrists, dorsal hands, trunk, thighs, shins, ankles, glans
penis
• Oral mucosa frequently affected with ulcers or reticulated white
patches
Vulvovaginal and perianal lesions show leukoplakia or erosions
• Scalp involvement (lichen planopilaris) causes scarring alopecia
Nail changes infrequent but can include pterygium
• Trauma may induce additional lesions (Koebner phenomenon)
Linear, annular, and hypertrophic variants
• Hepatitis C infection more prevalent in lichen planus patients;
screening indicated
• Skin biopsy when diagnosis not clear
• Differential Diagnosis
• Lichenoid drug eruption
• Pityriasis rosea
Psoriasis
Secondary syphilis
• Mucosal lesions: lichen sclerosus, candidiasis, erythema multiforme,
leukoplakia, pemphigus vulgaris, bullous pemphigoid
Discoid lupus erythematosus
• Treatment
• Topical or intralesional steroids for limited cutaneous or mucosal
lesions
• Systemic corticosteroids, psoralen plus UVA, oral isotretinoin,
low-molecular-weight heparin for generalized disease
• CycJosporine for severe cases
• Monitor for malignant transformation to squamous cell carcinoma
in erosive mucosal disease
• Aggressive management to avoid debilitating scarring in vulvar
lichen planus
• Pearl
To the uninitiated, oral lichen planus may be misdiagnosed as thrush,
leading to inappropriate assessment for immunocompromise.
Reference
Cribier Bet al: Treatment of lichen planus. An evidence-based medicine analysis
of efficacy. Arch Dermatol 1998; 134: 1521. [PMID: 99092348]
+
358 Essentials of Diagnosis & Treatment
Morbilliform Drug Eruption
• Essentials of Diagnosis
• Erythema, small papules
• Occurs within first 2 weeks of drug treatment; may appear later
• Pruritus prominent
• Eruption symmetric, beginning proximally and then generalizing
• Ampicillin, amoxicillin, allopurinol, and trimethoprim-sulfamethoxazole
most common causes
• Amoxicillin eruptions more frequent in patients with infectious
mononucleosis; sui fonamide rashes common in H1V-infected
patients
• Differential Diagnosis
• Viral exanthems
• Early stages of erythema multiforme major or drug hypersensitivity
syndrome
• Scarlet fever
• Toxic shock syndrome
• Acute graft-versus-host disease
• Treatment
• Discontinue offending agent unless this represents a greater risk
to the patient than the eruption
• Topical corticosteroids and oral antihistamines
• Avoid rechallenge in complex exanthems and in some HIV-infected
patients
• Pearl
No matter how obvious the cause ofthis or any such eruption, consider
syphilis.
Reference
Wolvenon SE: Update on cutaneous drug reactions. Adv Dermatol 1997; I 3:65.
[pMID: 98212498]
Chapter 15 Dermatologic Disorders 359
Photosensitive Drug Eruption
+
• Essentials of Diagnosis
• Morphology variable; photodistribution critical to diagnosis
• Phototoxic reactions resemble sunburn; related to dose of both
medication and UV radiation; tetracyclines, amiodarone, furosemide,
thiazides, phenothiazines, sulfonylureas, and NSAIDs
common causes
Photoallergic reactions typically red, scaly, pruritic; immunerelated
Pseudoporphyria caused by naproxen, tetracyclines, furosemide,
dapsone, and other medications
Photodistributed lichenoid reactions most frequently due to thiazides,
quinidine, NSAIDs
• Differential Diagnosis
• Porphyria cutanea tarda or other porphyrias
• Lupus erythematosus or dermatomyositis
• Photoallergic contact dermatitis
• Phototoxic contact dermatitis
• Polymorphous light eruption or other idiopathic photosensitivity
disorders
• Pellagra
• Xeroderma pigmentosum or other genetic photosensitivity disorders
• Treatment
• Avoid ance of the causative agent
• Sun avoidance, protection with broad-spectrum sunscreens containing
physical blockers
• Soothing local measures or topical corticosteroids
• Pearl
UVA radiation is the most common trigger, so broad-spectrum sunscreens
are essential.
Reference
Gould JW et al: Cutaneous photosensitivity diseases induced by exogenous
agents. J Am Acad Dermatol 1995;33:551. [PMID: 95403739]
+
360 Essentials of Diagnosis & Treatment
Fixed Drug Eruption
• Essentials of Diagnosis
• Lesions recur at same site with each repeat exposure to the causative
medication
• From one to six lesions
• Oral, genital, facial, and acral lesions most common
• Lesions begin as erythematous, edematous, round, sharply demarcated
patches or plaques
• May evolve to targetoid, bullous, or erosive
• Postinflammatory hyperpigmentation common
• Offending agents: NSAIDs, sulfonamides, barbiturates, tetracyclines,
erythromycin, and laxatives with phenolphthalein
• Differential Diagnosis
• Bullous pemphigoid
• Erythema multiforrne
• Sweet's syndrome (acute febrile neutrophilic dermatosis)
• Residual hyperpigmentation can appear similar to pigmentation
left behind by numerous other inflammatory disorders
• The differential of genital lesions includes psoriasis, lichen planus,
and syphilis
• Treatment
• Avoidance of the causative agent
• Symptomatic care of lesions
• Pearl
Fixed drug eruption should always be considered in the differential
diagnosis ofpenile erosions.
Reference
Korkij W et aJ: Fixed drug eruption. A brief review. Arch Dermatol 1984;
120:520. [PMID: 84152903]
Chapter 15 Dermatologic Disorders 361
+
Bullous Drug Reactions (Erythema Multiforme Major,
Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis)
• Essentials of Diagnosis
• Flu-like symptoms frequently precede eruption
• Initial lesions erythematous and macular; may become targetoid,
fonn bullae, or may desquamate
• Two or more mucosal surfaces (oral, conjunctival, anogenital)
usually affected; gastrointestinal tract or respiratory tract involved
In severe cases
• Skin biopsies confirm diagnosis
• Stevens-Johnson syndrome: < 10% of body surface involvement;
toxic epidermal necrolysis: > 30% of body surface involvement
• Sulfonamide drugs, phenytoin, carbamazepine, phenobarbital,
penicillins, allopurinol, and NSAIDs most frequent offenders
• In anticonvulsant hypersensitivity reactions, hepatitis, nephritis,
or pneumonitis may occur
• Differential Diagnosis
• Generalized bullous fixed drug eruption
• Staphylococcal scalded skin syndrome
• Infection-induced erythema multiforme major (most frequently
associated with Mycoplasma pneumoniae infection)
• Early disease may be confused with morbilliform drug eruptions
or erythema multiforme minor
• Bullous pemphigoid and pemphigus vulgaris
• Graft-versus-host disease
• Treatment
• Discontinuation of provocative agent
• Extensive involvement may require transfer to a bum unit for
fluid and electrolyte management
• Antibiotics
• Systemic corticosteroids is controversial
• Wet dressings, oral and ophthalmologic care, pain relief
• Intravenous immunoglobulin may be considered in severe cases
of toxic epidennai necrolysis
• Rechallenge with phenytoin, carbamazepine, or phenobarbital
should be avoided because cross-reactivity is common; vaiproic
acid is an alternative
• Pearl
Be very wary of~pikingfevers and systemic symptoms in patients taking
potentially offending drugs; it may take days until the rash appears.
Reference
Roujeau JC et al: Medication use and the risk of Stevens-Johnson syndrome or
toxic epidermal necrolysis. N Engl J Med 1995;333: 1600. [PMID: 96072888]
+
362 Essentials of Diagnosis &Treatment
Diffuse Pruritus
• Essentials of Diagnosis
• May be idiopathic, but workup needed to rule out the internal
causes
• Excoriations are an objective sign of pruritus but not always
present
• Differential Diagnosis
• Hepatic disease, especially cholestatic
• Hepatitis C with or without liver failure
• Uremia
• Hypothyroidism or hyperthyroidism
• Intestinal parasites
• Polycythemia vera
• Lymphomas, leukemias, myeloma, other malignancies
• Neuropsychiatric diseases (anorexia nervosa, delusions of parasitosis)
• Scabies
• Treatment
• Sedative antihistamines for symptomatic relief
• Topical menthol lotions
• Aspirin for pruritus of polycythemia vera
• Cholestyramine, naloxone, prednisone, and colchicine helpful in
some with hepatobiliary pruritus
• Optimization of dialysis, erythropoietin (epoetin alfa), emollients,
cholestyramine, phosphate binders. and phototherapy helpful in
some with uremic pmritus
• Pearl
Excoriatiolls spare areas out ofthe patient's reach, such as the "butterfly
Wile" 011 the back.
Reference
Kantor GR et al: Generalized pruritus and systemic disease. J Am Acad Dermato\
\983;9:375. [PMID: 840334\ J]
Chapter 15 Dermatologic Disorders 363
+
Lichen Simplex Chronicus & Prurigo Nodularis
• Essentials of Diagnosis
• Chronic, severe, localized itching
• Lichen simplex chronicus: well-circumscribed, erythematous
plaques with accentuated skin markings, often on the extremities
and posterior neck
• Prurigo nodularis: multiple pea-sized firm, erythematous or brownish,
dome-shaped, excoriated nodules, typically on the extremities
• Differential Diagnosis
• Lichen simplex chronicus: secondary phenomenon in atopic dermatitis,
stasis dermatitis, insect bite reactions, contact dermatitis,
or pruritus of other cause
• Lesions of psoriasis, cutaneous lymphoma, lichen planus, and
tinea corporis may resemble lichen simplex chronicus
• Prurigo nodularis: associated with HIV disease, renal failure,
hepatic diseases (especially hepatitis), atopic dermatitis, anemia,
emotional stress, pregnancy, and gluten enteropathy
• Prurigo nodularis: similar to hypertrophic lichen planus and scabietic
nodules
• Treatment
• Avoid scratching involved areas-occlusion with steroid tape,
semipermeable dressings, or even Unna boots may be of value
• Intralesional steroids or topical superpotent steroids helpful in
treating individual lesions; topical doxepin or capsaicin creams
sometimes effective
• Oral antihistamines of limited benefit
• Phototherapy, isotretinoin, topical caIcipotriene, and oral cyclosporine
are alternatives
• Thalidomide in recalcitrant, severe prurigo nodularis-pregnancy
prevention and monitoring for side effects are critical
• Pearl
These lesions are a response to chronic rubbing or picking: no specific
cause is suggested.
Reference
Jones RO: Lichen simplex chronicus. Clin Podiatr Med Surg 1996;13:47.
[PMID: 97002584]
-
+
364 Essentials of Diagnosis & Treatment
Acne Vulgaris
• Essentials of Diagnosis
• Often occurs at puberty, though onset may be delayed until the
third or fourth decade
• Open and closed comedones the haJlmarks
• Severity varies from comedonal to papular or pustular inflammatory
acne to cysts or nodules
• Face, neck, upper chest, and back may be affected
• Pigmentary changes and severe scarring can occur
• Differential Diagnosis
• Acne rosacea, perioral dermatitis, gram-negative folliculitis, tinea
faciei, and pseudofolliculitis
• Trunk lesions may be confused with staphylococcal folliculitis,
miliaria, or eosinophilic folliculitis
• May be induced by topical, inhaled, or systemic steroids, oily topical
products, and anabolic steroids
• Foods neither cause nor exacerbate acne
• In women with resistant acne, hyperandrogenism should be considered;
may be accompanied by hirsutism and irregular menses
• Treatment
• Improvement usually requires 4--6 weeks
• Topical retinoids very effective for comedonal acne but usefulness
limited by irritation
• Topical benzoyl peroxide agents
• Topical antibiotics (erythromycin combined with benzoyl peroxide,
c1indamycin) effective against comedones and mild inflammatoryacne
• Oral antibiotics (tetracycline, doxycycline, rninocycline) for moderate
inflammatory acne; erythromycin is an alternative when
tetracyclines contraindicated
• Low-dose oral contraceptives containing a nonandrogenic progestin
can be effective in women
• Diluted intralesional corticosteroids effective in reducing highly
inflammatory papules and cysts
• Oral isotretinoin useful in some who fail antibiotic therapy; pregnancy
prevention and monitoring essential
• Surgical and laser techniques available to treat scarring
• Pearl
Don't waste time continuing failing therapies in scarring acne-treat
aggressively ifneeded to prevent further scars.
Reference
Leyden JJ: Therapy for acne vulgaris. N Engl J Med 1997;336:1156. [PMID:
97238758]
Chapter 15 Dermatologic Disorders 365
Rosacea
+
• Essentials of Diagnosis
• A chronic disorder of the mid face in middle-aged and older
people
• History of flushing evoked by hot beverages, alcohol, or sunlight
• Erythema, sometimes persisting for hours or days after flushing
episodes
• Telangiectases become more prominent over time
• Many patients have acneiform papules and pustules
• Some advanced cases show large inflammatory nodules and nasal
sebaceous hypertrophy (rhinophyma)
• Differential Diagnosis
• Acne vulgaris
• Seborrheic dermatitis
• Lupus erythematosus
• Dermatomyositis
• Carcinoid syndrome
• Topical steroid-induced rosacea
• Polymorphous light eruption
• Demodex (mite) folliculitis in HIV-infected patients
• Perioral dermatitis
• Treatment
• Treatment is suppressive and chronic
• Topical metronidazole and oral tetracyclines effective against
papulopustular disease
Daily sunscreen use and avoidance of flushing triggers helpful in
slowing progression
Oral isotretinoin can produce dramatic improvement in resistant
cases, but relapse common
Laser therapy may obliterate telangiectases
Surgery in severe rhinophyma
• Pearl
Watch for ocular symptoms-blepharitis, conjunctivitis, or even keratitis
may occur in up to 58% ofpatients.
Reference
Wilkin JK: Rosacea. Arch Deonatol 1994;130:359. [PMTD: 94175563]
+
366 Essentials of Diagnosis & Treatment
Erysipelas &Cellulitis
• Essentials of Diagnosis
• Cellulitis: an acute infection ofthe subcutaneous tissue, most frequently
caused by Streptococcus pyogenes or Staphylococcus
aureus
• Erythema, edema, tenderness are the hallmarks of cellulitis; vesicles,
exudation, purpura, necrosis may follow
• Lymphangitic streaking may be seen
• Demarcation from uninvolved skin indistinct
• Erysipelas: involves superficial dermal lymphatics
• Erysipelas characterized by a warm, red, tender, edematous plaque
with a sharply demarcated, raised, indurated border; classically
occurs on the face
• Both erysipelas and cellulitis require a portal of entry
• Recurrence seen in lymphatic damage or venous insufficiency
• A prodrome of malaise, fever, and chills may accompany either
entity
• Differential Diagnosis
• Acute contact dermatitis
• Scarlet fever
• Lupus erythematosus
• Erythema nodosum
• Early necrotizing fasciitis or clostridial gangrene
• Underlying osteomyelitis
• Evolving herpes zoster
• Fixed drug eruption
• Venous thrombosis
• Beriberi
• Treatment
• Appropriate systemic antibiotics
• Local wound care and elevation
• Pearl
Look/or tinea pedis as a portal 0/entry in patients with leg cellulitis.
Reference
Danik SB el at: Cellulitis. Cutis 1999;64: 157. [PMTD: 10590915]
Chapter 15 Dermatologic Disorders 367
Folliculitis, Furuncles, &Carbuncles
+
• Essentials of Diagnosis
• Folliculitis: thin-walled pustules at follicular orifices, particularly
extremities, scalp, face, and buttocks; develop in crops and heal
in a few days
Furuncle: acute, round, tender, circumscribed, perifollicular abscess;
most undergo central necrosis and rupture with purulent discharge
• Carbuncle: two or more confluent furuncles with multiple sites of
drainage
• Classic folliculitis caused by S aureus
• Staphylococcal infections increased in mv-infected patients, diabetics,
alcoholics, and dialysis patients
• Differential Diagnosis
• Pseudofolliculitis barbae
• Acne vulgaris and acneiform drug eruptions
• Pustular miliaria (heat rash)
• Fungal folliculitis
• Herpes folliculitis
• Hot tub folliculitis caused by pseudomonas
Gram-negative folliculitis (in acne patients on long-term antibiotic
therapy)
Eosinophilic folliculitis (AIDS patients)
Nonbacterial folliculitis (occlusion or oil-induced)
Hidradenitis suppurativa of axillae or groin
• Dissecting cellulitis of scalp
• Treatment
• Thorough cleansing with antibacterial soaps
• Mupirocin ointment in limited disease
• Oral antibiotics (dicloxacillin or cephalexin) for more extensive
involvement
• Warm compresses and systemic antibiotics for furuncles and
carbuncles
• Culture for methicillin-resistant strains in unresponsive lesions
• Avoid incision and drainage with acutely inflamed lesions; may
be helpful when furuncle becomes localized and fluctuant
• Culture anterior nares in recurrent cases to rule out S aureus
Mupirocin, oral rifampin to anterior nares for S aureus
• Pearl
When these lesions occur without obvious cause, a glycosylated hemoglobin
may reveal diabetes.
Reference
Rhody C: Bacterial infections of the skin. Prim Care 2000;27:459. [PMID:
10815055]
+
368 Essentials of Diagnosis & Treatment
Tinea Corporis (Ringworm)
• Essentials of Diagnosis
• Single or multiple circular, sharply circumscribed, erythematous,
scaly plaques with elevated borders and central clearing
• Frequendy involves neck, extremities, and trunk
• A deep, pustular fonn affecting the follicles (Majocchi's granuloma)
may occur
• Other types affect face (tinea faciei), hands (tinea manuum), feet
(tinea pedis), and groin (tinea cruris)
• Skin scrapings for microscopic examination or culture establish
diagnosis
• Widespread tinea may be presenting sign of HIV infection
• Differential Diagnosis
• Pityriasis rosea
• Impetigo
• Nummular dermatitis
• Seborrheic dermatitis
• Psoriasis
• Granuloma annulare
• Secondary syphilis
• Subacute cutaneous lupus erythematosus
• Treatment
• One or two uncomplicated lesions usually respond to topical antifungals
(allylamines or azoles)
• A low-potency steroid cream during initial days of therapy may
decrease inflammation
• Oral griseofulvin standard therapy in extensive disease, follicular
involvement, or in the irnmunocompromised host-itraconazole
and terbinafine also effective
• Infected household pets (especially cats and dogs) may transmit
and should he treated
• Pearl
Be wary of combination products containing antifungals and potent
steroids: skin atrophy and reduced efficacy may result.
Reference
Drake LA et al: Guidelines of care for superficial mycotic infections of the skin.
JAm Acad Dermatol 1996;34:282. [PMlD: 08642094]
Chapter 15 Dermatologic Disorders 369
Onychomycosis (Tinea Unguium)
+
• Essentials of Diagnosis
• Yellowish discoloration, piling up of subungual keratin, friability,
and separation of the nail plate
• May show only overlying white scale if superficial
• Nail shavings for immediate microscopic examination, culture,
or histologic examination with periodic acid-Schiff stain to establish
diagnosis; repeated sampling may be required
• Differential Diagnosis
• Candida! onychomycosis shows erythema, tenderness, swelling
of the nail fold (paronychia)
• Psoriasis
• Lichen planus
• Allergic contact dermatitis from nail polish
• Contact urticaria from foods or other sensitizers
• Nail changes associated with reactive arthritis, Darier's disease,
crusted scabies
• Treatment
• Antifungal creams not effective
Oral terbinafine and itraconazole effective in many
Establish diagnosis before initiating therapy
• Adequate informed consent critical; patients must decide if benefits
of oral therapy outweigh risks
• Weekly prophylactic topical antifungals to suppress tinea pedis
may prevent tinea unguium recurrences
• Pearl
There is a significant recurrence rate after oral therapy.
Reference
Epstein E: How often does oral treatment of toenail onychomycosis produce a
disease-free nail~ An analysis of published data. Arch Dermatol 1998;
134:1551. [PMTD: 9875192]
+
370 Essentials of Diagnosis & Treatment
Tinea Versicolor (Pityriasis Versicolor)
• Essentials of Diagnosis
• Finely scaling patches on upper trunk and upper arms, usually
asymptomatic
• Lesions yellowish or brownish on pale skin, or hypopigmented
on dark skin
• Caused by yeast of the malassezia species
• Shon, thick hyphae and large numbers of spores on microscopic
examination
• Wood's light helpful in defining extent of lesions
• Differential Diagnosis
• Seborrheic dermatitis
• PitYliasis rosea
• Pityriasis alba
• Hansen's disease (leprosy)
• Secondary syphilis (macular syphilid)
• Vitiligo
• PostinAammatory pigmentary alteration from another inAammatory
dermatosis
• Treatment
• Topical agents in limited disease (selenium sulfide shampoos or
lotions, zinc pyrithione shampoos, imidazole shampoos, topical
allylami nes)
• Oral agents in more diffuse involvement (single-dose ketoconazole
repeated after I week, or 5-7 days of itraconazole)
• Oral terbinafine not effective
• Dyspigmentation may persist for months after effective treatment
• Relapse likely if prophylactic measures not taken; a single monthly
application of topical agent may be effective
• Pearl
Scrapings look like "spaghetti and meatballs"-the only entity in medicine
best described as an Italian dinner entree.
Reference
Drake LA et aI: Guidelines of care for superficial mycotic infections of the skin:
Pityriasis (tinea) versicolor. J Am Acad Dermatol 1996;34:287. [PMJD:
08642095]
Chapter 15 Dermatologic Disorders 371
Cutaneous Candidiasis
+
• Essentials of Diagnosis
• Candidal intertrigo causes superficial denuded, pink to beefy-red
patches that may be surrounded by tiny satellite pustules in genitocrural,
subaxillary, gluteal, interdigital, and submammary areas
• Oral candidiasis shows grayish white plaques that scrape off to
reveal a raw, erythematous base
• Oral candidiasis more common in elderly, debilitated, malnourished,
diabetic, or HIY-infected patients as well as those taking
antibiotics, systemic steroids, or chemotherapy
• Angular cheilitis (perleche) sometimes due to candida
Perianal candidiasis may cause pruritus ani
• Candidal paronychia causes thickening and erythema of the nail
fold and occasional discharge of thin pus
• Differential Diagnosis
• Candidal intertrigo: dermatophytosis, bacterial skin infections,
seborrheic dermatitis, contact dermatitis, deep fungal infection,
inverse psoriasis, erythrasma, eczema
• Oral candidiasis: lichen planus, leukoplakia, geographic tongue,
herpes simplex infection, erythema multiforme, pemphigus
• Candidal paronychia: acute bacterial paronychia, paronychia associated
with hypoparathyroidism, celiac disease, acrodermatitis
enteropathica, or reactive arthritis
• Chronic mucocutaneous candidiasis
• Treatment
• Control exacerbating factors (eg, hyperglycemia in diabetics,
chronic antibiotic use, estrogen-dominant oral contraceptives,
systemic steroids, ill-fitting dentures, malnutrition)
• Treat localized skin disease with topical azoles or polyenes
• Soaks with aluminum acetate solutions for raw, denuded lesions
• Fluconazole and itraconazole for systemic therapy
• Nystatin suspension or clotrimazole troches for oral disease
• Treat chronic paronychia with topical imidazoles or 4% thymol
in chloroform
Avoid chronic water exposure
• Pearl
The key in cutaneous candidiasis: is it local. systemic, or due to immunosuppression?
The history gives the answer.
Reference
Hay RJ: The management of superficial candidiasis. J Am Acad Dennatol
1999;40(6 Part 2):S35. [PMID: 10367915]
+
372 Essentials of Diagnosis & Treatment
Herpes Simplex
• Essentials of Diagnosis
• Orolabial herpes: initial infection usually asymptomatic; gingivostomatitis
may occur
• Recurrent grouped blisters on erythematous base (cold sore or
fever blister); lips most frequently involved
• UV exposure a common trigger
• Genital herpes: primary infection presents as systemic illness with
grouped blisters and erosions on penis, rectum, or vagina
Recurrences common, present with painful grouped vesicles; active
lesions infectious; asymptomatic shedding also occurs
• A prodrome of tingling, itching, or burning
• More severe and persistent in immunocompromised patients
• Eczema herpeticum is diffuse, superimposed upon a preexisting
inflammatory dermatosis
• Herpetic whitlow; infection of fingers or hands
• Tzanck smears, fluorescent antibody tests, viral cultures, and skin
biopsies diagnostic
• Differential Diagnosis
• Impetigo
• Zoster
• Syphilis, chancroid, lymphogranuloma venereum, or granuloma
inguinale
• Oral aphthosis, coxsackievirus infection (herpangina), erythema
multiforme, pemphigus, or primary HIV infection
• Treatment
• Sunblock to prevent orolabial recurrences
• Early acute intermittent therapy with acyclovir, famciclovir, or
valacyclovir
• Prophylactic suppressive therapy for patients with frequent recurrences
• Short-term prophylaxis before intense sun exposure, dental procedures,
and laser resurfacing for patients with recurrent orolabial
disease
• Suppressive therapy for immunosuppressed patients
• Intravenous foscarnet for resistance
• Pearl
Think ofgenital herpes in chronic heel pain-the virus lives in the sacral
ganglion and refers pain to that site.
Reference
Conant MA et al: Genital herpes. J Am Acad Dermatol 1996;35:601. [pMID:
97012475]
Chapter 15 Dermatologic Disorders 373
Zoster (Herpes Zoster, Shingles)
+
• Essentials of Diagnosis
• Occurs unilaterally within the clistribution of a sensory nerve with
some spillover into neighboring dermatomes
• Prodrome of pain and paresthesia followed by papules and plaques
of erythema which quickly develop vesicles
• Vesicles become pustular, crust over, and heal
• May disseminate (20 or more lesions outside the primary dermatome)
in the elderly, debilitated, or immunosuppressed; visceral
involvement (lungs, liver, or brain) may follow
• Involvement of the nasal tip (Hutchinson's sign) a harbinger of
ophthalmic zoster
• Ramsay Hunt syndrome (ipsilateral facial paralysis, zoster of
the ear, and auditory symptoms) from facial and auditory nerve
involvement
• Postherpetic neuralgia more common in older patients
• Tzanck smears useful but cannot differentiate zoster from zosteriform
herpes simplex
• Direct fluorescent antibody test rapid and specific
• Differential Diagnosis
• Herpes simplex infection
Prodromal pain can mimic the pain of angina, duodenal ulcer,
appendicitis, and biliary or renal colic
• Zoster 30 times more common in the illV-infected; ascertain illY
risk factors
• Treatment
• Heat or topical anesthetics locally
• Antiviral therapy
Intravenous acyclovir for disseminated or ocular zoster
• Bed rest to reduce risk of neuralgia in the elderly
• Prednisone does not prevent neuralgia
• Topical capsaicin, local anesthetics, nerve blocks, analgesics, tricyclic
antidepressants, and gabapentin for postherpetic neuralgia
• Patients with active lesions should avoid contact with neonates
and immunosuppressed individuals
• Pearl
"Shingles"-the word-is a linguistic corruption from Latin cingulum
("girdle"), reflecting the common thoracic presentation ofthis disorder.
Reference
Cohen Jl et al: Recent advances in varicella-roster virus infection. Ann Intern
Med 1999;130:922. [PMID: 99296103]
+
374 Essentials of Diagnosis & Treatment
Molluscum Contagiosum
• Essentials of Diagnosis
• Patients with AIDS, particularly those with a CD4 count of less
than 100/,uL, are at highest risk; large lesions on face and genitalia
• Patients with malignancies, sarcoidosis, extensive atopic dermatitis,
or history of diffuse topical steroid use are also predisposed
• Smooth, firm, dome-shaped, pearly papules; characteristic central
umbilication and white core
• Frequently generalized in young children
• Sexually transmitted in immunocompetent adults; usually with
less than 20 lesions; on lower abdomen, upper thighs, and penile
shaft
• Differential Diagnosis
• Warts
• Varicella
• Bacterial infection
• Basal cell carcinoma
• Lichen planus
• Cutaneous cryptococcal infection may mimic molluscum lesions
in patients with AIDS
• Treatment
• Avoid aggressive treatment in young children; possible therapies
for children include topical tretinoin or imiquimod, or continuous
application of occlusive tape
• Cryotherapy, curettage, or a topical agent (eg, podophyllotoxin)
for adults with genital disease
• Antiretroviral therapies resulting in increasing CD4 counts are
most effective for mv-infected patients
• Pearl
As in so many other cases, this once trivial disease was made prominent
by the HIVepidemic.
Reference
Lewis EJ et al: An update on molluscum contagiosum. Cutis 1997;60:29.
[pMID: 9252731]
Chapter 15 Dermatologic Disorders 375
Common Warts (Verrucae Vulgares)
+
• Essentials of Diagnosis
• Scaly, rough, spiny papules or plaques
• Most frequently seen on hands, may occur anywhere on skin
• Caused by human papiUomavirus
• Differential Diagnosis
• Actinic keratosis
• Squamous cell carcinoma
• Seborrheic keratosis
• Acrochordon (skin tag)
• Nevus
• Molluscum contagiosum
• Verrucous zoster in HIV-infected patients
• Extensive warts suggest epiderrnodysplasia verruciformis, HlV
infection, or Iymphoproliferative disorders
• Treatment
• Avoid aggressive treatment in young children; spontaneous resolution
is common
• Cryotherapy
• Patient-applied salicylic acid products
• Office-applied cantharidin
• Curettage and electrodesiccation
• Pulsed dye laser therapy
• Sensitization with squaric acid in resistant cases
• Intralesional bleomycin
• Oral cimetidine has low efficacy but may be a useful adjunct
• Topical imiquimod less effective in common warts than genital
warts
• Pearl
The first tumor ofHomo sapiens proved to be caused by a virus.
Reference
Benton EC: Therapy of cutaneous warts. Clin Derrnatol 1997; 15:449. lPMID:
97399323]
+
376 Essentials of Diagnosis & Treatment
Genital Warts (Condylomata Acuminata)
• Essentials of Diagnosis
• Gray, yellow, or pink lobulated multifocal papules
• Occur on the penis, vulva, cervix, perineum, crural folds, or perianal
area; also may be intraurethral or intra-anal
• Caused by human papillomavirus; sexually transmitted
• Increased risk of progression to cervical cancer, anal cancer, or
bowenoid papulosis in certain HPV subtypes
• Children with genital warts should be evaluated for sexual abuse,
but childhood infection can also be acquired via perinatal vertical
transmission or digital autoinoculation
• Differential Diagnosis
• Psoriasis
• Lichen planus
• Bowenoid papulosis and squamous cell carcinoma
• Seborrheic keratosis
• Pearly penile papules
• Acrochordon (skin tag)
• Secondary syphilis (condyloma latum)
• Treatment
• Treatment may remove lesions but has not been shown to reduce
transmission or prevent progression to cancer
• Cryotherapy, topical podophyllum resin, topical trichloroacetic
acid, electrofulguration, and carbon dioxide laser; plume generated
by lasers or electrofulguration is potentially infectious to health
care personnel
• Imiquimod is as effective as cryotherapy; women have a higher
response rate than men
• Pap smear for women with genital warts and female sexual partners
of men with genital warts
• Biopsy suspicious lesions; HTV-infected patients with genital
warts are at increased risk of HPV-induced carcinomas
• Pearl
Subclinical disease, common and impossible to eradicate, is neither
investigated nor treated.
Reference
Beutner KR et al: Genital warts and their treatment. elin Infect Dis 1999;
28(Suppll):S37. [PMID: 99152435]
Chapter 15 Dermatologic Disorders 377
Pediculosis
+
• Essentials of Diagnosis
• Three types of lice (Pediculus humanus), each with a predilection
for certain body parts
• Dermatitis caused by inflammatory response to louse saliva
• Pediculosis capitis (head lice): intense scalp pruritus, presence of
nits, possible secondary impetigo and cervical lymphadenopathy;
most common in children, rare in blacks
• Pediculosis corporis (body lice): rarely found on skin, causes
generalized pruritus, erythematous macules or urticarial wheals,
excoriations and lichenification; homeless and those living in
crowded conditions most frequently affected
• Pediculosis pubis (crabs): usually sexually transmitted; generally
limited to pubic area, axillae, and eyelashes; lice may be observed
on skin and nits on hairs; maculae ceruleae (blue macules) may
be seen
• Body lice can transmit trench fever, relapsing fever, and epidemic
typhus
• Differential Diagnosis
• Head lice: impetigo, hair casts, seborrheic dermatitis
Body lice: scabies, urticaria, impetigo, dermatitis herpetiformis
Pubic lice: scabies, anogenital pruritus, eczema
• Treatment
• Head lice: topical permethrins with interval removal of nits and
re-treatment in j week.
Pyrethrins available over the counter; resistance common
• Treat household contacts
• Body lice: launder clothing and bedding (at least 30 minutes at
j 50 OF in dryer, or iron pressing of wool garments); patient
should then bathe; no pesticides required
Puhic lice: LTeatment is same as for head lice; eyelash lesions
treated with thick coating of petrolatum maintained for j week;
recurrence is more common in HIV-infected patients
• Pearl
Body lice infestation is an underappreciated cause ofiron deficiency in
the homeless population.
Reference
Chosidow 0: Scabies and pediculosis. Lancet 2000;355:819. [PMID: 10711939]
+
378 Essentials of Diagnosis &Treatment
Scabies
• Essentials of Diagnosis
• Caused by Sarcoptes scabiei mite
• Pruritogenic papular eruption favoring finger webs, wrists, antecubital
fossae, axillae, lower abdomen, genitals, buttocks, and
nipples
• Itching usually worse at night
Face and scalp are spared (except in children and the immunosuppressed)
• Burrows appear as short, slightly raised, wavy lines in skin, sometimes
with vesicles
• Secondary eczematization, impetigo, and lichenification in longstanding
infestation
• Red nodules on penis or scrotum
• A crusted form in institutionalized, illY-infected, or malnourished
individuals
• Burrow scrapings permit microscopic confirmation of mites, ova,
or feces; many cases diagnosed on clinical grounds
• Differential Diagnosis
• Atopic dermatitis
Papular urticaria
• Insect bites
• Dermatitis herpetiformis
• Pediculosis corporis
• Pityriasis rosea
• Treatment
• Permethrin 5% cream applied from the neck down for 8 hours;
clothing and bed linens laundered thoroughly; repeat therapy in
I week
• Lindane used infrequently because of potential toxicity
• Oral ivermectin in refractory cases, institutional epidemics, or
immunosuppressed patients
• Treat all household and sexual contacts
• Persistent postscabietic pruritic papules may require topical or
intralesional corticosteroids
• Pearl
A condition occurring in all walks oflife. not only in the underserved.
Reference
Chosidow 0: Scabies and pediculosis. Lancet 2000;355:819. [PMID: 10711939]
Chapter 15 Dermatologic Disorders 379
Erythema Multiforme Minor
+
• Essentials of Diagnosis
• Uniformly associated with herpes simplex infection (orolabial
more than genital)
• Episodes follow orolabial herpes by 1-3 weeks and may recur
with succeeding outbreaks
• Early sharply demarcated erythematous papules which become
edematous
• Later "target" lesions with three zones: central duskiness that
may vesiculate; edematous, pale ring; and surrounding erythema
• Dorsal hands, dorsal feet, palms, soles, and extensor surfaces
most frequently affected, with few to hundreds of lesions
• Mucosal involvement (usually oral) in 25%
• Biopsies often diagnostic
• Differential Diagnosis
• Stevens-Johnson in evolution
• Pemphigus vulgaris
• Bullous pemphigoid
• Urticaria
• Acute febrile neutrophilic dermatosis (Sweet's syndrome)
• Treatment
• Chronic suppressive anti herpetic therapy prevents 90% of recurrences
• Facial and lip sunscreens may also decrease recurrences by limiting
herpes outbreaks
• Episodes usually self-limited (resolving in 1-4 weeks) and do not
require therapy
• Systemic corticosteroids discouraged
• Pearl
Even when a history ofherpes cannot be elicited, empiric antivirals may
prevent recurring target lesions.
Reference
Singla R et al: Erythema multiforme due to herpes simplex virus. Recurring target
lesions are the clue to diagnosis. Postgrad Med 1999;106:151. [PMID:
20024264]
+
380 Essentials of Diagnosis & Treatment
Cutaneous Kaposi's Sarcoma
• Essentials of Diagnosis
• Disease limited to the lower extremities, spreads slowly
• Classic form occurs in elderly men of Mediterranean, East European,
or Jewish descent
Vascular neoplasm presenting with one or several red to purple
macules which progress to papules or nodules
• African endemic form cutaneous and locally aggressive in young
adults or lymphadenopathic and fatal in children
AIDS-associated form shows cutaneous lesions on head, neck,
trunk, and mucous membranes; may progress to nodal, pulmonary,
and gastrointestinal involvement
• The form associated with iatrogenic immunosuppression can
mimic either classic or AIDS-associated type
• Human herpesvirus 8 the causative agent in all types
• Skin biopsy for diagnosis
• Differential Diagnosis
• Dermatofibroma
• Bacillary angiomatosis
• Pyogenic granuloma
• Prurigo nodularis
• Blue nevus
• Melanoma
• Cutaneous lymphoma
• Treatment
• In AIDS-associated cases, combination antiretroviral therapyincreasing
CD4 counts-is the treatment of choice
• Intralesional vincristine or interferon, radiation therapy, cryotherapy,
alitretinoin gel, laser ablation, or excision
• Systemic therapy with liposomal doxorubicin or other cytotoxic
drugs in certain cases with rapid progression or visceral involvement
• Pearl
The first alert to the H1Vepidemic was a New York dermatologist reporting
two cases ofatypical Kaposi's sarcoma to the Centers for Disease
Control-a single physician giving thought to a patient's problem
can still make a difference.
Reference
Antman K et al: Kaposi's sarcoma. N Engl J Medicine 2000;342: 1027. [PMID:
10749966]
Chapter 15 Dermatologic Disorders 381
Seborrheic Keratosis
+
• Essentials of Diagnosis
• Age at onset generally fourth to fifth decades
• Oval, raised, brown to black, warty, "stuck on"-appearing, welldemarcated
papules or plaques; greasy hyperkeratotic scale may
be present
• Usually multiple; some patients have hundreds
• Chest and back most frequent sites; scalp, face, neck, and extremities
also involved
• Rapid eruptive appearance of numerous lesions (Leser-Trelat
sign) may signify internal malignancy
• Differential Diagnosis
• Melanoma
• Actinic keratosis
• Nevus
• Verruca vulgaris
• Solar lentigo
• Basal cell carcinoma, pigmented type
• Squamous cell carcinoma
• Dermatosis papulosa nigra in dark-skinned patients; numerous
small papules on face, neck, and upper chest
• Stucco keratosis shows hyperkeratotic, gray, verrucous, exophytic
papules on the extremities, can be easily scraped off
• Treatment
• Seborrheic keratoses do not require therapy
• Cryotherapy or curettage effective in removal, may leave dyspigmentation
• Electrodesiccation and laser therapy
• Pearl
A public health menace this is not, but look closely at all such lesions
to exclude cutaneous malignancies.
Reference
Pariser RJ: Benign neoplasms of the skin. Med Clin North Am 1998;82:1285.
[pMID: 9889749]
+
382 Essentials of Diagnosis & Treatment
Actinic Keratosis (Solar Keratosis)
• Essentials of Diagnosis
• Most common in fair-skinned individuals and in organ transplant
recipients and other immunocompromised patients
• Discrete keratotic, scaly papules; red, pigmented, or skin-colored
• Found on the face, ears, scalp, dorsal hands, and forearms
• Induced by chronic sun exposure
• Lesions may become hypertrophic and develop a cutaneous horn
• Lower lip actinic keratosis (actinic cheilitis) presents as diffuse,
slight scaling of the entire lip
• Some develop into squamous cell carcinoma
• Differential Diagnosis
• Squamous cell carcinoma
• Bowen's disease (squamous cell carcinoma in-situ)
• Seborrheic keratosis
• Discoid lupus erythematosus
• Treatment
• Cryotherapy standard when limited number of sites present
• Topical fluorouracil effective for extensive disease; usually causes
a severe inflammatory reaction
• Laser therapy for severe actinic cheilitis
• Biopsy atypical lesions or those that do not respond to therapy
• Sun protection, sunscreen use
• Pearl
In patients with facial pain, check for a history of actinic keratosis;
when these lesions become carcinomas, they can invade the local sheath
ofthe fifth cranial nerve and produce this symptom.
Reference
5alasche 5J: Epidemiology of actinic keratoses and squamous cell carcinoma.
J Am Acad Dermatol 2000;42( I Part 2):4. [PMID: 10607349]
Chapter 15 Dermatologic Disorders 383
Basal Cell Carcinoma
+
• Essentials of Diagnosis
• Dome-shaped semitranslucent papule with overlying telangiectases,
or a plaque of such nodules around a central depression;
central area may crust or ulcerate
• Most occur on head and neck, but the trunk and extremities also
affected
Pigmented, cystic, sclerotic, and superficial clinical variants
• Immunosuppressive medications increase frequency and aggressiveness;
patients with albinism or xeroderma pigmentosum or
exposed to radiation therapy or arsenic also at increased risk
• Chronic, local spread typical, metastasis rare
• Biopsy critical for diagnosis
• Differential Diagnosis
• Squamous cell carcinoma
• Actinic keratosis
• Seborrheic keratosis
• Paget's disease
• Melanoma
• Nevus
• Psoriasis
• Nevoid basal cell carcinoma syndrome
• Treatment
• Simple excision with histologic examination of margins
• Curettage with electrodesiccation in superficial lesions of trunk
or small nodular tumors in select locations
Mohs' microsurgery with immediate mapping of margins for
lesions with aggressive histology, recurrences, or in areas where
tissue conservation is important
• Ionizing radiation is an alternative
Sun protection, regular sunscreen use, regular skin screening
• Pearl
An extremely common malignancy-with millions of cases annually
worldwide.
Reference
Goldberg LH: Basal cell carcinoma. Lancet 1996;347:663. [PMID: 96175905]
+
384 Essentials of Diagnosis & Treatment
Squamous Cell Carcinoma
• Essentials of Diagnosis
• Chronic UY exposure, certain HPY infections, radiation exposure,
long-standing scars, certain HIY infections, and chronic immunosuppression
predispose
• Immunosuppressed renal transplant patients may have 250 times
the baseline risk
Patients with albinism, xeroderma pigmentosum, and epidermodysplasia
verruciformis at increased risk
Hyperkeratotic, firm, indurated, red or skin-colored papule, plaque,
or nodule, most commonly in sun-damaged skin
May ulcerate and form crust; many arise in actinic keratoses
Lesions confined to the epidermis are squamous cell carcinoma
in-situ or Bowen's disease; all others are considered invasive
• Metastasis infrequent but devastating; lesions on lip or in scars
and those with subcutaneous or perineural involvement are at
higher risk
• Regional lymphatics primary route of spread
• Skin biopsies usually diagnostic
• Differential Diagnosis
• Keratoacanthoma (a rapidly growing and sometimes selfinvoluting
variant of squamous cell carcinoma)
• Actinic keratosis, hypertrophic form
• Basal cell carcinoma
• Verruca vu19aris
• Chronic nonhealing ulcers due to other causes (venous stasis,
infection, etc)
• Treatment
• Simple excision with histologic examination of margins
• Mohs' microsurgery with immediate TTllipping of margins for highrisk
lesions or in areas where tissue conservation is important
• Curettage and electrodesiccation in small in-situ lesions
• Ionizing radiation
Evaluate patients with aggressive lesions or perineural involvement
on histologic examination for metastatic disease
Prophylactic radiotherapy in high-risk lesions
Regular screening examinations and sun protection
• Pearl
The main reason to treat all actinic keratoses: preventing this.
Reference
Goldman GD: Squamous cell cancer: a practical approach. Semin Cutan Med
Surg 1998;17:80. [PMID: 98332265]
Chapter 15 Dermatologic Disorders 385
Malignant Melanoma
+
• Essentials of Diagnosis
• Higher incidence in those with fair skin, blue eyes, blond or red
hair, blistering sunburns, chronic sun exposure, family history,
immunodeficiency, many nevi, dysplastic nevi, giant congenital
nevus, and certain genetic diseases such as xeroderma pigmentosum
• ABCD warning signs: Asymmetry, Border irregularity, Color
variegation, and Diameter over 6 mm
• Clinical characteristics vary depending on subtype and location
• Early detection is critical; advanced-stage disease has high mortality
• Epiluminescence microscopy to identify high-risk lesions
• Biopsies for diagnosis must be deep enough to permit measurement
of thickness; partial biopsies should be avoided
• Differential Diagnosis
• Seborrheic keratosis
• Basal cell carcinoma, pigmented type
• Nevus (ordinary melanocytic nevus, dysplastic nevus)
• Solar lentigo
• Pyogenic granuloma
• Kaposi's sarcoma
• Pregnancy-associated darkening of nevi
• Treatment
• Prognosis for localized disease determined by histologic features
• Appropriate staging workup including history, physical examination,
laboratory tests, and scans to evaluate for metastatic spread
• Sentinel lymph node biopsy; lymph node dissection if evidence
of lymphatic disease
• Reexcision with appropriate margins determined by histologic
characteristics of the tumor
• Adjuvant therapy for high risk
• Close follow-up
• Pearl
When a mole is suspicious or changing, it belongs infonnalin.
Reference
Lang PG Jr: Malignant melanoma. Med Clin North Am 1998;82: 1325.
[PMTD: 9889751]
+
386 Essentials of Diagnosis & Treatment
Nevi (Congenital Nevi, Acquired Nevi)
• Essentials of Diagnosis
• Common acquired nevi have homogeneous surfaces and color
patterns, smooth and sharp borders, and are round or oval in shape
• Color may vary from Aesh-colored to brown
• Rat or raised depending on the subtype or stage of evolution
• Excisional biopsy to rule out melanoma in changing nevi or those
with ABCD warning signs (see Malignant Melanoma)
• Congenital nevi darkly pigmented; sometimes hairy papules or
plaques that may be present at birth
• Large congenital nevi (those whose longest diameter will be
greater than 20 em in adulthood) are at increased risk for melanoma;
when found on head, neck, or posterior midline, associated
with underlying leptomeningeal melanocytosis
• Differential Diagnosis
• Dysplastic nevus
• Melanoma
• Lentigo simplex
• Solar lentigo
• Dermatofibroma
• Basal cell carcinoma
• Molluscum contagiosum
• Blue nevus
• Cafe au lait spot
• Epidermal nevus
• Becker's nevus
• Treatment
• Excision of cosmetically bothersome nevi, and for those at high
risk of developing melanoma
• Biopsy suspicious lesions
• Partial hiopsies should he avoided when excisional hiopsies feasible
• Head or spinal scans in children with large congenital nevi occurring
on the head, neck, or posterior midline
• Pearl
Any nevus with suspicious features should be considered melanoma
until proved otherwise.
Reference
Schleicher SM et al: Congenital nevi. Int J Dermatol 1995;34:8259. [PMID:
8647657]
Chapter 15 Dermatologic Disorders 387
Bullous Pemphigoid
+
• Essentials of Diagnosis
• Age at onset seventh or eighth decade, though also occurs in
young children
• Caused by autoantibodies to two specific components of the hemidesmosome
• Occasionally drug-induced (penicillamine, furosemide, captopril,
enalapril, penicillin, sulfasalazine, nalidixic acid)
• Large, tense blisters that rupture, leaving denuded areas which
heal without scarring
• Erythematous patches and urticarial plaques even in the absence
of bullae
• Predilection for groin, axillae, flexor forearms, thighs, and shins;
may occur anywhere; some have oral involvement
• Frequently pruritic
• Diagnosis by lesional biopsy, perilesional direct immunofluorescence,
and indirect immunofluorescence
• Differential Diagnosis
• Epidermolysis bullosa acquisita
• Cicatricial pemphigoid
• Herpes gestation is
• Linear IgA dermatosis
• Dermatitis herpetiformis
• Treatment
• Prednisone initially
• Nicotinamide plus tetracycline
• Aggressive immunosuppression may be required (azathioprine,
low-dose methotrexate, or mycophenolate mofetil); monitor patients
for side effects and infections
• Topical steroids for localized mild disease that breaks through
medical LTeatment
• Pemphigoid usually self-limited, lasting months to years
• Pearl
With adequate therapy, most patients achieve lasting remission.
Reference
Nousari He et al: Pemphigus and bullous pemphigoid. Lancet 1999;354:667.
[PMTD: 10466686]
+
388 Essentials of Diagnosis & Treatment
Pemphigus Vulgaris
• Essentials of Diagnosis
• Presents in fifth or sixth decade
• Caused by autoantibodies to desmogleins; occasionally druginduced
(penicillamine, captopril)
• Thin-walled, fragile blisters; rupture to fonn painful erosions that
crust and heal slowly without scarring
• Most initially present with oral involvement
• Scalp, face, neck, axillae, and groin common sites; esophagus, trachea,
conjunctiva, and other mucosal surfaces may also be involved
• Lateral pressure applied to perilesional skin induces more blistering
(Nikolsky's sign)
• Diagnosis by lesional biopsy of intact blisters, perilesional direct
immunofluorescence, indirect immunofluorescence
• Differential Diagnosis
• Paraneoplastic pemphigus (usually associated with lymphomas
and leukemias)
• Pemphigus foliaceus
• Fogo selvagem (endemic Brazilian pemphigus)
• Bullous pemphigoid
• Erythema multi forme, Stevens-Johnson syndrome, toxic epidermal
necrolysis
• Linear IgA dermatosis
• Epidennolysis bullosa acquisita
• Patients presenting with only oral lesions may be misdiagnosed
with aphthous stomatitis, erythema multiforme, herpes simplex,
lichen planus, or cicatricial pemphigoid
• Treatment
• Viscous lidocaine and antibiotic rinses for oral erosions
• Early and aggressive systemic therapy required; mortality high in
untreated patients
• High doses of oral prednisone combined with another immunosuppressive
(azathioprine or mycophenolate mofetil)
• Monitor for side effects and infections
• Plasmapheresis, intravenous immune globulin, and intramuscular
gold are alternatives
• Pearl
Before the advent ofcorticosteroids, this disease was often fatal.
Reference
Nousari He et al: Pemphigus and bullous pemphigoid. Lancet 1999;354:667.
[PMJD: J0466686]
Chapter 15 Dermatologic Disorders 389
Urticaria (Hives) &Angioedema
+
• Essentials of Diagnosis
• Pale or red, evanescent, edematous papules or plaques surrounded
by red halo (flare) with severe itching or stinging; appear suddenly
and resolve in hours
• Acute (complete remission within 6 weeks) or chronic
• Subcutaneous swelling (angioedema) occurs alone or with urticaria;
eyelids and lips often affected; respiratory tract involvement may
produce airway obstruction, and gastrointestinal involvement may
cause abdominal pain; anaphylaxis possible
• Can be induced by drugs (penicillins, aspirin, other NSAlDs, opioids,
radiocontrast dyes, ACE inhibitors)
Foods a frequent cause of acute urticaria (nuts, strawberries, shellfish,
chocolate, tomatoes, melons, pork, garlic, onions, eggs, milk,
azo dye additives)
• Infections also a cause (streptococcal upper respiratory infections,
viral hepatitis, helminthic infections, or infections of the
tonsils, a tooth, sinuses, gallbladder, prostate)
• Differential Diagnosis
• Hereditary or acquired complement-mediated angioedema
Physical urticarias (pressure, cold, heat, solar, vibratory, cholinergic,
aquagenic)
Urticarial hypersensitivity reactions to insect bites
Urticarial vasculitis
Bullous pemphigoid
• Erythema mulriforme
• Granuloma annulare
• Lyme borreliosis (erythema migrans)
• Treatment
• Treat acute urticaria with antihistamines and avoid identified triggers;
short course of prednisone in some cases
• Chronic urticaria treated with antihistamines on a regular rather
than as-needed basis; chronic prednisone discouraged
• Second-generation nonsedating antihistamines during waking
hours
• Workup to rule out usual triggers
• Pearl
Angiotensin-converting enzyme (ACE) inhibitor-inauced angioedema
may occur at any time-even years-after beginning the medicine.
Reference
Greaves MW: Chronic urticaria. N Engl J Med 1995; 332:1767. [PMID:
95281009]
+
390 Essentials of Diagnosis & Treatment
Granuloma Annulare
• Essentials of Diagnosis
• White or red flat-topped, asymptomatic papules that spread with
central clearing to form annular plaques; cause unknown
• May coalesce, then involute spontaneously
• Predilection for dorsum of fingers, hands, or feet; elbows or ankles
also favored sites
• Generalized form sometimes associated with diabetes; subcutaneous
form most common in children
• Skin biopsy secures diagnosis
• Differential Diagnosis
• Necrobiosis Jipoidica
• Tinea corporis
• Erythema migrans (Lyme disease)
• Sarcoidosis
• Secondary syphilis
• Erythema multiforme
• Subacute cutaneous lupus erythematosus
• Annular lichen planus
• Leprosy (Hansen's disease)
• Rheumatoid nodules (subcutaneous form)
• Treatment
• None required in mild cases; 75% of patients with localized disease
cIear in 2 years
• lntralesional or potent topical corticosteroids effective for single
lesions
• Prednisone contraindicated in generalized disease due to relapse
upon withdrawal
• Anecdotal success with dapsone, nicotinamide, potassium iodide,
systemic retinoids, antimalarials, and psoralen plus UVA (PUVA)
• Pearl
Suspect HIV infection in generalized granuloma annulare in nondiabetics.
Reference
Smith MD et al: Granuloma annulare. Int J Dermatol 1997;36:326. [PMTD:
97343421]
Chapter 15 Dermatologic Disorders 391
+
Discoid (Chronic Cutaneous) Lupus Erythematosus
• Essentials of Diagnosis
• Dull red macules or papules developing into sharply demarcated
hyperkeratotic plaques with follicular plugs
• Lesions heal from the center with atTophy, dyspigmentation, and
telangiectasias
• Localized lesions most common on scalp, nose, cheeks, ears,
lower lip, and neck
• Scalp lesions cause scarring alopecia
• Generalized disease involves trunk and upper extremities
• Cutaneous involvement only rarely progresses to systemic lupus
erythematosus, but one-fourth of SLE patients develop OLE
• Abnormal serologies, leukopenia, and albuminuria identify
OLE patients likely to progress; children with OLE more likely
to progress
• Skin biopsy for diagnosis; direct immunofluorescence
• Differential Diagnosis
• Seborrheic dermatitis
• Rosacea
• Lupus vulgaris (cutaneous tuberculosis)
• Sarcoidosis
• Bowen's disease (squamous cell carcinoma in-situ)
• Polymorphous light eruption
• Tertiary syphilis
• Lichen planopilaris of the scalp
• Treatment
• Screen for systemic disease with history, physical, and laboratory
tests
• Aggressive sun protection, including a high-SPF sunscreen
• Potent topical corticosteroids or intralesional steroids for localized
lesions
• Systemic therapy with antimalarials
• Monitor laboratory studies; ophthalmologic consultation every
6 months
• Thalidomide in resistant cases; pregnancy prevention and monitoring
for side effects critical
• Pearl
Relapses are common, and long-term therapy is often required.
Reference
Donnelly AM et aI: Discoid lupus erythematosus. Australas J Dermatol
1995;36:3. [PMTD: 7763220]
+
392 Essentials of Diagnosis &Treatment
Androgenetic Alopecia (Common Baldness)
• Essentials of Diagnosis
• Genetic predisposition plus excessive androgen response
• Men in third and fourth decades: gradual loss of hair, chiefly from
vertex and frontotemporal regions; rate variable
• Women: diffuse hair loss throughout the mid scalp, sparing frontal
hairline
• Appropriate laboratory workup for women with signs of hyperandrogenism
(hirsutism, acne, abnormal menses)
• Hair pull test may show a normal or increased number oftelogen
hairs; hair shafts narrow but not fragile
• Differential Diagnosis
• Telogen effluvium
• Alopecia induced by hypothyroidism
• Alopecia induced by iron deficiency
• Secondary syphilis
• Trichotillomania
• Tinea capitis
• Alopecia areata in evolution
• Treatment
• Early topical minoxidil effective in about one-third with limited
disease
• Oral finasteride prevents further loss and increases hair counts
(except on the temples); contraindicated in women of childbearing
potential; lacks efficacy in postmenopausal women
• Wigs or interwoven hair for cosmetic purposes
• Hair transplantation with minigrafts
• Women with hyperandrogenism may respond to antiandrogen
therapies
• Pearl
Anxious patients with this condition support an enormous market for
uninvestigated products.
Reference
Drake LA et al: Guidelines for care of androgenetic alopecia. J Am Acad Dermatol
1996;35:465. [PMJD: 96378724]
Chapter 15 Dermatologic Disorders 393
Alopecia Areata
+
• Essentials of Diagnosis
• Usually occurs without associated disease, but patients with alopecia
areata have an increased incidence of atopic dermatitis,
Down's syndrome, lichen planus, vitiligo, autoimmune thyroiditis,
and systemic lupus erythematosus
• Rapid and complete hair loss in one or several round or oval
patches
• Occurs on the scalp or in the beard, eyebrows, or eyelashes; other
hair-bearing areas less frequently affected
• Short broken hairs on patch periphery
• During active disease, telogen hairs near the patches easily pulled;
gray hairs spared
• The patches show preservation of follicles and normal scalp
• Some patients have nail pitting
• Some progress to total loss of scalp hair (alopecia totalis); a few
lose all body hair (alopecia universalis)
Biopsy with horizontal sectioning if diagnosis unclear
• Differential Diagnosis
• Tinea capitis
• Discoid lupus erythematosus, early lesions
Lichen planopilaris, early lesions
Secondary syphilis
• Trichotillomania
• Metastatic or cutaneous malignancy
• Loose anagen syndrome
• Androgenic alopecia
• Treatment
• Course is variable: some patches regrow spontaneously, others
resist therapy
• Intralesional steroid injections for regrowth
• Topical anthralin, corticosteroids, or minoxidil, contact sensitization
with squaric acid, and psoralens plus UVA
• Psychologic stress can be devastating; emotional support, patient
education essential
• Pearl
Spontaneous recovery is common in patients with limited disease who
are postpubertal at onset.
Reference
Price VH: Treatment of hair loss. N Engl J Med 1999;341 :964. [PMlD:
99412080]
+
394 Essentials of Diagnosis & Treatment
Vitiligo
• Essentials of Diagnosis
• Depigmented white patches surrounded by a normal, hyperpigmented,
or occasionally inflamed border
• Hairs in affected area usually tum white
• Localized form may affect one nondermatomal site or may be
segmental
• Usually treatment-resistant
• Generalized form most common; involvement symmetric and
tends to affect skin around orifices
• Universal form depigments entire body surface
• Acrofacial form affects the distal fingers and facial orifices
• Ocular abnormalities (iritis, uveitis, and retinal pigmentary abnormalities)
increased in vitiligo patients
• Associated with insulin-dependent diabetes, pernicious anemia,
autoimmune thyroiditis, alopecia areata, and Addison's disease
• Differential Diagnosis
• Leukoderma associated with metastatic melanoma
• Occupational vitiligo from phenols or other chemicals
• Morphea
• Lichen sclerosis
• Tinea versicolor
• Pityriasis alba
• Postinflammatory hypopigmentation
• Hansen's disease (leprosy)
• Cutaneous T cell lymphoma
• Lupus erythematosus
• Piebaldism
• Tuberous sclerosis
• Treatment
• Spontaneous repigmentation infrequently occurs
• Cosmetic camouflage
• Sun protection to avoid severe burns in affected areas
• Potent topical steroids in focal lesions may help repigment
• Psoralen plus UVA may help in generalized disease, but inadvertent
bums are common
• Total permanent depigmentation with monobenzone an option in
extensive disease
• Patient education, emotional support
• Pearl
An under-appreciated part of the endocrine immunopathies: its presence
should callfor thyroid, adrenal, and gastric antibody studies.
Reference
Kovacs SO: Vitiligo. J Am Acad Dermatol 1998;38(5 Part 1):647. [PMID:
9591808]
Chapter 15 Dermatologic Disorders 395
Melasma (Chloasma Faciei)
+
• Essentials of Diagnosis
• Most frequently seen in women during pregnancy or menopausealso
associated with oral contraceptives and phenytoin use
• Well-demarcated symmetric brown patches with irregular borders
• Typically on cheeks and forehead but may also involve nipples,
genitals, or forearms
• Exacerbated by sun exposure
• Differential Diagnosis
• Postinftammatory hyperpigmentation
• Contact photodermatitis from perfumes
• Exogenous ochronosis (from hydroquinones, phenol, or resorcinol)
• Drug-induced hyperpigmentation (minocycline, gold, etc)
• Treatment
• Sun protection, including broad-spectrum sunscreen with UVA
coverage
• Bleaching creams with hydroquinone moderately effective, sometimes
combined with topical retinoids and mild topical steroid
(contraindicated during pregnancy or lactation)
• Pearl
Pregnancy-induced melasma clears within months; medication-induced
disease persists for years.
Reference
Grimes PE: Melasma. Etiologic and therapeutic considerations. Arch Dermatol
1995; 131 :1453. [PMTD: 96094883]
+
396 Essentials of Diagnosis & Treatment
Acanthosis Nigricans
• Essentials of Diagnosis
• Symmetric velvety hyperpigmented plaques on axillae, groin, and
neck; the face, umbilicus, inner thighs, anus, flexor surfaces of
elbows and knees, and mucosal surfaces may also be affected
• Associated with insulin-resistant states such as obesity
• Laboratory evaluation of testosterone and DHEAS levels in
women with the type A syndrome of insulin resistance
Patients with the type B syndrome have acanthosis nigricans and
insulin resistance secondary to anti-insulin receptor autoantibodies
generated by autoimmune diseases
• Associated with some drugs (testosterone, nicotinic acid, oral
contraceptives, corticosteroids)
• Widespread lesions or disease occurring in a nonobese patient
arouse suspicion of malignant acanthosis nigricans associated
with adenocarcinomas of the stomach, lung, and breast
• Workup for malignancy ifpalmar involvement present
• Differential Diagnosis
• Confluent and reticulated papillomatosis of Gougerot and Carteaud
• Epidermal nevus
• Dowling-Degos disease
• Treatment
• Weight loss for obese patients
• Malignant form often responds to treatment of the causal tumor
• Pearl
May be a harbinger ofimpending diabetes even before fasting glucose
levels are elevated.
Reference
Schwanz RA: Acanthosis nigricans. J Am Acad DermalOl 1994;31: I. [PMID:
94292614]
Chapter 15 Dermatologic Disorders 397
Erythema Nodosum
+
• Essentials of Diagnosis
• A reactive inflammation of the subcutis associated with infections
(streptococcal, tuberculous, yersinia, salmonella, shigella,
systemic fungal infections), drugs (oral contraceptives, sulfonamides,
bromides), sarcoidosis, and inflammatory bowel disease
• Symmetric, erythematous, tender plaques or nodules 1-10 cm in
diameter on anterior shins
• Lesions also seen on upper legs, neck, and arms
• Onset accompanied by malaise, leg edema, and arthralgias
• Lesions flatten over a few days leaving a violaceous patch, then
heal without atrophy or scarring
• All lesions generally resolve within 6 weeks
• Chronic form with prolonged course not associated with underlying
diseases
• Deep skin biopsy for diagnosis
• Differential Diagnosis
• Erythema induratum (secondary to tuberculosis)
• Nodular vasculitis
Poststeroid panniculitis
• Lupus panniculitis
Erythema multiforme
Syphilis
Subcutaneous fat necrosis associated with pancreatitis
• Treatment
• Treat underlying causes
• Bed rest, gentle support hose; avoid vigorous exercise
• NSAIDs
• Potassium iodide
• Intralesional steroids in persistent cases
• Systemic steroids in severe cases; contraindicated when the
underlying cause is infectious
• Pearl
Chronic lesions unresponsive to therapy should prompt a workup for
subclinical tuberculosis infection.
Reference
Cribier B et al: Erythema nodosum and associated diseases. Int J Dermatol
1998;37:667. [PMTD 98433780]
+
398 Essentials of Diagnosis & Treatment
Pyoderma Gangrenosum
• Essentials of Diagnosis
• Often chronic and recurrent; may be accompanied by a polyarticular
arthritis
Associated with inlhmmatory bowel disease and lymphoproliferative
disorders; also seen with hepatitis B or C, HlV infection,
systemic lupus erythematosus, pregnancy, and other conditions
• Up to half of cases idiopathic
• Lesions begin as inflammatory pustules, sometimes at a trauma
site
• Erythematous halo enlarges, then ulcerates
• Ulcers painful with ragged, undermined, violaceous borders;
bases appear purulent
• Ulcers heal slowly, form atrophic scars
• Diagnosis of exclusion; biopsies with special stains and cultures
to rule out infections (mycobacterial, fungal, tertiary syphilis, gangrene,
amebiasis)
• Differential Diagnosis
• Folliculitis, insect bites, or Sweet's syndrome (acute febrile neutrophilic
dermatosis)
• Ulcers secondary to underlying infection
• Ulcers secondary to underlying neoplasm
• Factitious ulcerations from injected substances
• Vasculitis (especially Wegener's granulomatosis)
• Coumarin necrosis
• Treatment
• Treat inflammatory bowel disease when present
• Local compresses, occlusive dressings, potent topical steroids,
intralesional steroids, or topical tacrolimus
• High-dose systemic steroids in widespread disease; if control is not
estahlished or if a steroid taper is unsuccessful, a steroid-sparing
agent (cyclosporine, mycophenolate mofetil, etc) is added
• Dapsone, sulfasalazine, and clofazimine also steroid-sparing
• Pearl
Often confused with factitious ulcerations as the clinical presentations
are quite similar.
Reference
Powell FC et al: Pyoderma gangrenosum. Clin DermatoI2000;18:283. [PMID:
10856660]
Chapter 15 Dermatologic Disorders 399
Leg Ulcers From Venous Insufficiency
+
• Essentials of Diagnosis
• Occurs in patients with signs of venous insufficiency
• Irregular ulcerations, often on medial aspect of lower legs; fibrinous
eschar at the base
• Light rheography to assess venous insufficiency
• Measurement of the ankle/brachial index to eliminate arterial
component
• Atypical or persistent ulcers should be biopsied to rule out other
causes
• Differential Diagnosis
• Arterial insufficiency
• Pyoderma gangrenosum
• Diabetic neuropathy and microangiopathy
• Vasculitis
• Cryoglobulins
• Infection (mycobacteria, fungi)
• Trauma
• Sickle cell anemia or thalassemia
• Neoplasm (eg, basal cell or squamous cell carcinoma, melanoma,
lymphoma)
• Treatment
• Clean ulcer base, remove eschar regularly
• Topical antibiotics (metronidazole) reduce bacterial growth and
odor; topical steroids when inflammation present
• Cover ulcer with occlusive permeable biosynthetic dressing
• Compression therapy with Unna's boot or elastic bandage essential
• Becaplermin (recombinant platelet-derived growth factor) in diabetics
with refractory ulcers
• Cultured epidermal cell grafts or bilayered skin substitutes in
highly refractory ulcers
• Compression stockings to reduce edema and risk of further ulcerations
• Pearl
Venous stasis ulcers disappear as arterial insiifficiency develops-no
preload, no ulcer.
Reference
Alguire PC et al: Chronic venous insufficiency and venous ulceration. J Gen
Intern Med 1997;12:374. [PMID: 9192256]
18
Gynecologic, Obstetric,
I. Breast Disorders
Abnormal Uterine Bleeding
• Essentials of Diagnosis
• Excessive menses, intermenstrual bleeding, or both; postmenopausal
bleeding
• Common soon post-menarche, 4--6 years pre-menopause
• Differential Diagnosis
• Pregnancy (especially ectopic), spontaneous abortion
• Anovulation (eg, polycystic ovaries, hypothyroidism)
• Uterine myoma or carcinoma, polyp, trauma
• Cervicitis, carcinoma of the cervix
• Adenomyosis
• Exogenous hormones (eg, unopposed estrogen, medroxyprogesterone
acetate, levonorgestrel, oral contraceptives)
• Coagulation disorders (eg, von Willebrand's disease)
• Treatment
• Exclude pregnancy
• Transfusion, oral iron when deficiency proved
• Papanicolaou smear (all ages) and endometrial biopsy (all postmenopausal
women and those over age 35 with chronic anovulation
or more than 6 months of bleeding)
• Active bleeding with significant anemia: high-dose estrogen
(25 mg intravenously or oral contraceptive taper: two pills twice
daily for 3 days tapering over 2 weeks to one daily); high-dose
progestin when high-dose estrogen contraindicated
• Chronic bleeding: oral contraceptives or cyclic progestin; NSAIDs
can reduce blood loss
• Hysterectomy or endometrial ablation for bleeding refractory to
hormonal therapy
• Hysterectomy if endometrial cancer, hyperplasia with atypia
• Pearl
Ectopic preglUlncy is considered first and promptly as the most serious
cause ofacute uterine (and intraperitoneal) blood loss.
Reference
Munro MG: Medical management of abnormal uterine bleeding. Obstet Gynecol
Clin North Am 2000;27:287. [PMTD: 10857120]
400
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 401
Dysmenorrhea
• Essentials of Diagnosis
• Occurs in 50% of menstruating women
• Low, midline, cramping pelvic pain radiating to back or legs;
pain starting before or with menses, peaking after 24 hours, and
subsiding after 2 days, often associated with nausea, diarrhea,
headache, and flushing
• Primary dysmenorrhea: pain without pelvic pathology and beginning
1-2 years after menarche
• Secondary dysmenorrhea: pain with underlying pathology such as
endometriosis or adenomyosis, developing years after menarche
• Differential Diagnosis
• Endometriosis
• Adenomyosis
• Uterine myoma
• Cervical stenosis, uterine anomalies
• Chronic endometritis or pelvic inflammatory disease
• Intrauterine device
• Treatment
• NSAIDs prior to the onset of bleeding, continued for 2-3 days
• Suppression of ovulation with oral contraceptives or medroxyprogesterone
acetate
• In secondary dysmenorrhea, laparoscopy may be needed diagnostically
• Pearl
Endometriosis is the most important cause; pregnancy is the treatment.
Reference
Coco AS: Primary dysmenorrhea. Am Fam Physician 1999;60:489. [PMID:
10465224]
+
402 Essentials of Diagnosis & Treatment
Mucopurulent Cervicitis
• Essentials of Diagnosis
• A sexually transmitted infection most commonly caused by Neisseria
gonorrhoeae or chlamydia; endocervical inflammation can
result from herpesvirus, trichomonas, or candida
• Usually asymptomatic but may have abnormal vaginal discharge,
postcoital bleeding, or dysuria
• Red, friable cervix with purulent, often blood-streaked endocervical
discharge
• Must be distinguished from physiologic ectopy of columnar epithelium
common in young women
• Differential Diagnosis
• Pelvic inflammatory disease
• Cervical carcinoma or dysplasia
• Cervical ulcer secondary to syphilis, chancroid, or granuloma
inguinale
• Normal epithelial ectopy
• Cervical inflammation due to vaginal infection
• Treatment
• In general, treat only if tests are positive for N gonorrhoeae or
chlamydia; empirically in a high risk or noncompliant patient
• Ceftriaxone for gonorrhea, erythromycin or doxycycline (once
pregnancy excluded) for chlamydiosis
• Sexual abstinence until treatment completed, with therapy for
partner
• Pearl
Any patient with cervicitis, irrespective of the cause, should be tested
for HIV, syphilis, and hepatitis C.
Reference
Miller KE et al: Update on the prevention and treatment of sexually transmitted
diseases. Am Fam Physician 2000;61 :379. [PMID: (Ul: 10670504]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 403
Vaginitis
• Essentials of Diagnosis
• Vaginal burning, pain, pruritus, discharge
• Results from atrophy, infection, or allergic reaction
• Common infectious causes include Candida albicans, Triclwmonas
vaginalis, bacterial vaginosis (gardnerella and other anaerobes)
• Trichomonas is sexually transmitted and causes profuse, malodorous
discharge and vaginal irritation
• Bacterial vaginosis may be asymptomatic or associated with a thin,
gray, "fishy" discharge
• C albicans associated with pruritus, burning, and a thick, white,
nonmalodorous discharge
• KOH and pH are usually diagnostic: Trichomonads are motile,
pH> 4.5; bacterial vaginosis reveals clue cells, pH> 4.5; hyphae
and spores with a normal pH «4.5) mean candida
• Differential Diagnosis
• Physiologic discharge, ovulation
• Atrophic vaginitis, vulvar dystrophies (lichen sclerosis), and vulvar
neoplasia in older women
• Cervicitis, syphilis, herpesvirus outbreak
• Cervical carcinoma
• Foreign body (retained tampon)
• Contact dermatitis (eg, condoms, perfumed products, soap)
• Pubic lice, scabies
• Treatment
• Limit vaginal irritants
• Culture cervix for Neisseria gonorrhoeae and chlamydia if no
other cause for symptoms
• For T vaginalis: metronidazole (2 g as a single dose) for both
patient and partner
• For r: alhir:am: antifungal (eg, clotrimazole) vaginal cream or
suppository or single-dose oral fluconazole (150 mg)
• For bacterial vaginosis: metronidazole (500 mg twice daily for
7 days or vaginal gel twice daily for 5 days)
• Pearl
Pubic lice may simulate vaginitis and may be seen in all walks of life
de;,pite the contrary bias.
Reference
Egan ME et aI: Diagnosis of vaginitis. Am Fam Physician 2000;62: 1095. [PMID:
10997533]
+
404 Essentials of Diagnosis & Treatment
Myoma of the Uterus
(Fibroid Tumor, leiomyoma, Fibromyoma)
• Essentials of Diagnosis
• Irregular enlargement of uterus caused by benign smooth muscle
tumors
• Occurs in 40-50% of women over age 40
• May be asymptomatic or cause heavy or irregular vaginal bleeding,
anemia, urinary frequency, pelvic pressure, dysmenorrhea
• Acute pelvic pain rare
• May be intramural, submucosal, subserosa!, intraligamemous,
cervical, or parasitic (ie, deriving its blood supply from an adjacent
organ)
• Pelvic ultrasound confirms diagnosis
• Differential Diagnosis
• Pregnancy
• Adenomyosis
• Ovarian or adnexal mass
• Abnormal uterine bleeding due to other causes
• Leiomyosarcoma
• Renal infarct
• Tamoxifen therapy
• Treatment
• Exclude pregnancy
• Papanicolaou smear and endometrial biopsy
• Pelvic examinations regularly for small asymptomatic myomas
• Hormonal therapy for menometrorrhagia
• GnRH agonists for 3--6 months for women planning surgery or
nearing menopause
• Medical therapies often ineffective for large or submucosal myomas;
resection may be necessary
• Pearl
Infarction of a myoma may cause a spectacular elevation in sentm
LDH, simulating hemolysis if the hematocrit is also falling from associated
bleeding.
Reference
Nowak RA: Fibroids: pathophysiology and current medical treatment. Baillieres
Best Pract Res Clin Obstet Gynaecol 1999; 13:223. [PMID: 10755039]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 405
Endometriosis
• Essentials of Diagnosis
• Seen in 10% of all menstruating women, 25% of infenile women
• Progressive, recurrent, characterized by aberrant growth of endometrium
outside the uterus
• Classic triad: cyclic pelvic pain, dysmenorrhea, and dyspareunia
• May be associated with infertility or pelvic mass
• Pelvic examination mayor may not be normal
• Hematochezia, painful defecation, or hematuria if bowel or bladder
invaded
• Ultrasound often normal
• Laparoscopy confirms diagnosis
• Differential Diagnosis
• Other causes of chronic pelvic pain
• Primary dysmenorrhea
• Adenomyosis
• Treatment
• NSATDs
• Ovulation suppression until fenility is desired
• GnRH analogs (eg, leuprolide) for no longer than 6 months
• Laparoscopy with ablation of lesions for refractory pain helpful
in up to two-thirds of patients; 50% recur
• Hysterectomy with bilateral salpingo-oophorectomy for those
who have completed childbearing
• Pearl
The only benign disease in medicine which behaves like metastatic carcinoma;
endometriosis occurs anywhere in the body, including fingers,
lungs, and other organs.
Reference
Wellbery C: Diagnosis and treatment of endometriosis. Am Fam Physician
1999;60: 1753. [PMlD: 10537390]
+
406 Essentials of Diagnosis & Treatment
Pelvic Inflammatory Disease
(PID, Salpingitis, Endometritis, Tubo-ovarian Abscess)
• Essentials of Diagnosis
• Most common in young, sexually active women with multiple
partners
• Upper genital tract associated with Neisseria gonorrhoeae and
Chlamydia trachomatis. anaerobes, Haemophilus irifluenzae. enteric
gram-negative rods, and streptococci
• A major cause of chronic pelvic pain, infertility and pelvic
adhesions
• Symptoms and severity vary
• Lower abdominal, adnexal, cervical motion tenderness; fever,
abnormal cervical discharge, leukocytosis
• Absence of competing diagnosis
• Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) from
associated perihepatitis
• Pelvic ultrasound may reveal a tubo-ovarian abscess.
• Laparoscopy for cases with uncertain diagnosis or no improvement
despite antibiotic therapy
• Differential Diagnosis
• Any cause of acute abdominal-pelvic pain or peritonitis
• Appendicitis, diverticulitis
• Ruptured ovarian cyst, ovarian torsion
• Ectopic pregnancy
• Acute cystitis, urinary calculi
• Treatment
• Oral antibiotics for mild cases (14-day course) covering N gonorr/
1Oeae and chlamydia
• Hospitalization and intravenous antibiotics for toxic, adolescent,
HIV-infected, or pregnant patients
• Surgical drainage of tubo-ovarian abscess
• Screen for HIV, hepatitis, syphilis
• Sexual abstinence until treatment completed; partner should be
treated
• Pearl
PID is occasionally if irreverently referred to as "Hollywood appendicitis"
in the entertainment industry.
Reference
Munday PE: Pelvic inflammatory disease-an evidence-based approach to diagnosis.
J Jnfect 2000;40:31. [PMTD: 10762109]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 407
Pelvic Organ Prolapse
• Essentials of Diagnosis
• Common in older multiparous women as a delayed result of childbirth
injury to pelvic floor
• Includes prolapse of the uterus, bladder, rectum, small bowel or
vaginal cuff
• Often asymptomatic; may have pelvic pressure or pulling, vaginal
bulge, low back pain, difficulties with defecation or voiding
• Pelvic examination confirms the diagnosis
• Prolapse may be slight, moderate, or marked
• Attenuation of pelvic structures with aging can accelerate development
• Differential Diagnosis
• Vaginal or cervical neoplasm
• Rectal prolapse
• Rectal carcinoma
• Treatment
• Supporti ve measures (eg, Kegel exercises), high-fiber diet,
weight reduction, and limit straining and lifting
• Conjugated estrogen creams to decrease vaginal irritation
Pessaries may reduce prolapse and its symptoms; ineffective for
very large prolapse
• Corrective surgery for symptomatic prolapse that significantly
affects quality of life
• Pearl
Lack ofawareness of this entity may result in misdiagnosis ofa pelvic
tumor or abscess; the history should provide the answer.
Reference
Shull BL: Pelvic organ prolapse: anterior, superior, and posterior vaginal segment
defects. Am J Obstet Gynecol 1999; 181 :6. [pMID: 10411783]
+
408 Essentials of Diagnosis & Treatment
Spontaneous Abortion
• Essentials of Diagnosis
Vaginal bleeding and pelvic pain and cramping before the
20th week of pregnancy
• Occurs in up to 20% of pregnancies
• Threatened abortion: pregnancy may continue or abortion may
ensue; cervix closed, bleeding and cramping mild, intrauterine
pregnancy confirmed
• Inevitable or incomplete abortion: cervix dilated and products of
conception mayor may not be partially expelled; brisk uterine
bleeding
• Complete abortion: products of conception completely expelled;
cervix closed, cramping and bleeding decreased
• Missed abortion (blighted ovum); failed pregnancy detected by
ultrasound; cervix closed, bleeding and cramping mild
• Serum ~-hCG low or falling except in threatened abortion
• Pelvic Ultrasonography contraindicated when bleeding heavy or
cervix open
• Differential Diagnosis
• Ectopic pregnancy
• Menorrhagia, menses, prolapsed uterine myoma
• Gestational trophoblastic neoplasia
• Cervical neoplasm or lesion
• Treatment
• Follow hematocrit closely
• Threatened abortion: ~-hCG in 2-3 days; immediate follow-up if
brisk bleeding develops
• Limiting activity ineffective
• Inevitable or incomplete abortion: immediate suction curettage
• Missed abortion: suction curettage or wait for spontaneous
ahortion
• Rho immune globulin to Rh-negative mothers
• Follow-up to ensure patient is no longer pregnant
• Pearl
Over-the-counter diagnostic kits resulting in early diagnosis of pregnancy
have demonstrated a high incidence ofthis disorder-in truth a
normal phenomenon in up to one-third ofconceptions.
Reference
Ansari AH et al: Recurrent pregnancy loss. An update. J Reprod Med 1998;
43:806. [PMlD: 9777621]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 409
Menopausal Syndrome
• Essentials of Diagnosis
• Cessation of menses without other cause, usually due to aging or
bilateral oophorectomy
Average age is 51; earlier in women who smoke
• Perimenopause: declining ovarian function over 4-6 years
• Menstrual irregularity, hot flushes, night sweats, vaginal dryness
• Elevated serum FSH and LH
• Differential Diagnosis
• Other causes of amenorrhea, especially pregnancy
• Hyperthyroidism or hypothyroidism
• Pheochromocytoma
• Uterine neoplasm
• Sjogren's syndrome
• Depression
• Anorexia
• Treatment
• Short-term hormonal therapy
• Hot flushes often resolve by 2-4 years after menopause
• For irregular bleeding, oral contraceptives, cyclic or combined
continuous estrogen plus progestin, or progestins alone
• Long-term hormone replacement therapy to decrease risk of
osteoporosis
• Estrogen cream and nonhorrnonallubricants for vaginal dryness
• Pearl
Menopause may on occasion be premature, a devastating event for a
nulliparous young woman; psychologic support is crucial in the early
care ofsuch patients.
Reference
Cutson TM et al: Managing menopause. Am Fam Physician 2000;61: 1391.
[PMTD: 10735345]
+
410 Essentials of Diagnosis & Treatment
Ectopic Pregnancy
• Essentials of Diagnosis
• Pregnancy implantation outside uterine cavity
• Occurs in 2% of pregnancies; most commonly presents 6-8 weeks
after last menstrual period
• Symptoms of pregnancy, missed menstrual period, vaginal bleeding
or spotting
• Pelvic pain may be absent, mild, or significant
• Tenderness on pelvic or abdominal examination; adnexal mass
sometimes palpable
• Cardiovascular collapse, shock with rupture in some
• Serum ~-hCG fails to rise appropriately during follow-up
• Transvaginal ultrasound to identify intrauterine gestation when
~-hCG is above about 2000 mlU/mL; an empty uterine cavity
when ~-hCG > 2000 is highly suspicious
• Transvaginal ultrasound often cannot demonstrate an extrauterine
pregnancy
• Diagnosis confirmed by lack of placental villi after suction curettage
or by laparoscopy
• Differential Diagnosis
• Intrauterine pregnancy (threatened abortion)
• Appendicitis
• Pelvic inflammatory disease (rare during pregnancy)
• Gestational trophoblastic neoplasia
• Ruptured corpus luteum cyst
• Urinary calculi
• Treatment
• Suction curettage
• Methotrexate for compliant patients with small, unruptured
ectopic pregnancies
• Surgical removal of larger or complicated ectopic pregnancies
• Emergent laparotomy if hemodynamically unstable with acute
abdomen
• Rho immune globulin to Rh-negative patients
• Periodically repeat ~-hCG until it falls to nonpregnant level
• Early ultrasound confirmation of future pregnancies (repeat ectopic
pregnancy occurs in about 10% of cases)
• Pearl
Pregnancy has been observed to proceed nearly to telm in the peritoneum.
Reference
Tay JI et al: Ectopic pregnancy. West J Med 2000;173: 131. [pMID: 10924442]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 411
Preeclampsia-Eclampsia
• Essentials of Diagnosis
• Progressive condition affecting 5-10% of pregnant women
• Preeclampsia is hypertension plus proteinuria; addition of seizures
means eclampsia
• Headache, blurred vision or scotomas, abdominal pain, altered
mental status
• Funduscopic evidence of acute hypertension, hyperreflexia; encephalopathy
• Thrombocytopenia, elevated AST or ALT, hemoconcentration or
hemolysis
• Pulmonary edema can occur
• HELLP syndrome: hemolysis, elevated liver enzymes and low
platelets
• Increased in primiparas and patients with history of preeclampsia,
hypertension, diabetes, chronic renal disease, autoimmune
disorders
• Differential Diagnosis
• Chronic hypertension due to other cause
• Chronic renal disease due to other cause
• Primary seizure disorder
Hemolytic uremic syndrome
• Thrombotic thrombocytopenic purpura
• Treatment
• The only treatment is delivery of the fetus
• Induce labor at or near term or for severe disease regardless of
gestational age
• Remote from term, mild cases can be observed in the hospital
with induction of labor for worsening disease
• Antihypertensives if blood pressure> 1801110 mm Hg; goal is
150/90 mm Hg
• For eclampsia, intravenous magnesium sulfate or diazepam
• Pearl
Deliver the baby, cure the disease.
Reference
Visser Wet al: Prediction and prevention of pregnancy-induced hypertensive
disorders. Baillieres Best Pract Res Clin Obstet Gynaecol 1999;13:131.
[PMTD: 10746098]
+
412 Essentials of Diagnosis & Treatment
Mammary Dysplasia (Fibrocystic Disease)
• Essentials of Diagnosis
• Common age 30-50
• Painful, often multiple, usually bilateral masses in the breasts
• Rapid fluctuation in size of masses
• Pain, increase in size during premenstrual phase of cycle
• Rare in postmenopausal women not on hormonal therapy
• Eighty percent of women have histologic fibrocystic changes
• Differential Diagnosis
• Breast carcinoma
• Fibroadenoma
• Fat necrosis
• Intraductal papilloma
• Treatment
• Biopsy to exclude carcinoma
• Ultrasound to differentiate cystic from solid masses
• Aspiration both diagnostic and therapeutic
• Regular breast self-examination
• Supportive brassiere (night and day), NSAIDs, oral contraceptives
• Danazol (l00-200 mg twice daily) for severe pain
• Pearl
Recognize that all women are appropriately fearful of breast cancer in
this condition and that medical management is only one part ofthe picture.
Reference
Zylstra S: Office management of benign breast disease. Clin Obstet Gynecol
1999;42:234. [PMlD: 10370844]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 413
Puerperal Mastitis
• Essentials of Diagnosis
• Occurs in nursing mothers within 3 months after delivery
• Unilateral inflammation of breast or one quadrant of breast
• Sore or fissured nipple with surrounding redness, tenderness,
induration, warmth, fever, malaise
• Increased incidence in first-time mothers
• Staphylococcus aureus and streptococci are usual causative agents
• May progress to breast abscess
• Ultrasound can confirm abscess diagnosis
• Differential Diagnosis
• Local irritation or trauma
• Benign or malignant tumors (inflammatory carcinoma)
• Subareolar abscess (occurs in nonlactating women)
• Fat necrosis
• Treatment
• For very mild cases, warm compresses and increased frequency
of breast feeding
Oral dicloxacillin or first-generation cephalosporin
• Hospitalize for intravenous antibiotics if no improvement in
48 hours in toxic patients
• Increase frequency of breast feeding with expression of any remaining
milk
• Incision and drainage for abscess; stop breast feeding from affected
breast (may pump milk and discard)
• Pearl
Women with this disorder may appear surprisingly toxic systemically,
diverting attention from this diagnosis.
Reference
Scott-Conner CE et al: The diagnosis and management of breast problems during
pregnancy and lactation. Am J Surg 1995;170:401. [PMID: 7573738]
+
414 Essentials of Diagnosis & Treatment
Chronic Pelvic Pain
• Essentials of Diagnosis
• Subacute pelvic pain of more than 6 months' duration
• Etiology often multifactorial
• Up to 40% have been physically or sexually abused
• Pain that resolves with ovulation suppression suggests gynecologic
cause; some nongynecologic conditions also improve with
ovulation suppression
• Concomitant depression very common
• Ultrasound is usually not diagnostic, nor is physical examination
• Halfof women who undergo laparoscopy have no visible pathology
• Differential Diagnosis
• Gynecologic: endometriosis, adenomyosis, pelvic adhesions, prior
PID or chronic PID, leiomyomas
• Gastrointestinal: irritable bowel syndrome, inflammatory bowel
disease, diverticular disease, constipation, neoplasia, hernia
• Urologic: detrusor overactivity, interstitial cystitis, urinary calculi,
urethral syndrome, bladder carcinoma
• Musculoskeletal: myofascial pain, low back pain, disk problems,
nerve entrapment, muscle strain or spasm
Psychiatric: somatization, depression, physical or sexual abuse,
anxiety
• Treatment
• Evaluate for and treat the above causes, including psychiatric
• NSAIDs; avoid opioids
• Ovulation suppression with oral contraceptives, medroxyprogesterone
acetate, or a short course of leuprolide acetate can be both
diagnostic and therapeutic
• Diagnostic laparoscopy if medical management fails or diagnosis
remains in question
• Hysterectomy with hilateral oophorectomy for refractory gynecologic
pain in women who have completed child-bearing
• Pearl
The most difficult management problem in primary care gynecology,
medically and psychologically.
Reference
Scialli AR: Evaluating chronic pelvic pain. A consensus recommendation.
Pelvic Pain Expert Working Group. J Reprod Med 1999;44:945. [PMID:
10589405]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 415
Cervical Dysplasia
• Essentials of Diagnosis
• Risk factors: early intercourse, multiple sexual partners, smoking,
HIV infection
• Includes low- and high-grade squamous intraepitheliallesions or
cervical intraepithelial neoplasia (CrN 1-3)
• Seventy-five percent of low-grade (ON I) regress spontaneously;
only 35% of high-grade (CIN 2-3) regress
• Atypical squamous cells of undetennined significance (ASCUS)
associated with underlying dysplasia in 10%; other causes are
benign reparative changes, inflammation
• Atypical glandular cells of undetermined significance (AGUS,
AGCUS) associated with significant abnormality (eg, endometrial
hyperplasia, adenocarcinoma, or high-grade dysplasia) in 40%
• Over 90% of squamous dysplasia and cancer due to sexually
transmitted infection with human papillomavirus (HPY)
• Colposcopy to confirm cytologic diagnosis and exclude invasive
cancer
• Differential Diagnosis
• Inflammation due to vaginitis, cervicitis or atrophy
• Inadequate specimen
• Inaccurate interpretation of cytology or histology
• Treatment
• Excision (loop electrosurgical excision procedure, cone biopsy)
or ablation (cryotherapy, laser)
• Atypical cells: treat vaginitis or atTophy if present; colposcopy for
recurrence
• Repeat Pap smear every 4-6 months until three consecutive normal
results are reported; routine screening thereafter
• Low-grade lesions: colposcopy with biopsy confirms diagnosis;
expectant management versus ahlation or excision
• High-grade lesions: colposcopy with biopsy to confirm diagnosis;
treat with ablation or excision
• Atypical squamous or glandular cells: colposcopy, endocervical
curettage, and, if abnormal bleeding is present, endometrial biopsy
• Pearl
Know your cytopathologist; staging is crucial in this condition.
Reference
Cox JT: Evaluation of abnormal cervical cytology. Clin Lab Med 2000;
20:303. [pMlD: 10863643]
+
416 Essentials of Diagnosis & Treatment
Amenorrhea
• Essentials of Diagnosis
• Absence of menses for over 3 months in women with past menses
(secondary amenorrhea); absence of menarche by age 16 (primary
amenorrhea)
• May be anatomic, ovarian, or hypothalamic-pituitary-ovarian
• Anatomic causes: congenital anomalies of the uterus, imperforate
hymen, cervical stenosis
• Ovarian failure: causes include autoimmune diseases, Turner's,
ovarian dysgenesis, radiation or chemotherapy
Hypothalamic-pituitary-ovarian causes most common; include
hyperandrogenic disorders, hypothalamic anovulation, hyperprolactinemia,
hypothyroidism, and hypothalamic or pituitary lesions
• Exclusion of pregnancy and measurement of TSH and prolactin
secures diagnosis
• FSH and LH to evaluate for premature ovarian failure or polycystic
ovarian syndrome
• Dehydroepiandrosterone sulfate and testosterone to exclude
androgen-secreting tumors
• Withdrawal bleeding in response to progestin (10 mg medroxyprogesterone
acetate for 10 days) indicates that the ovary produces
estrogen and that the uterus and outflow tract are intact
• Differential Diagnosis
• Pregnancy
• Physiologic (adolescence, perimenopause)
• Causes as outlined above
• Treatment
• Polycystic ovarian syndrome: oral contracepti ves offer cycle regularity,
decrease the risk of endometrial cancer caused by unopposed
estrogen, and treat associated acne and hirsutism
• Hypo-estTogenic causes: treat underlying disorder, estrogen treatment
to prevent osteoporosis
• Hyperprolactinemia: surgery for macroadenoma, otherwise treat
with bromocriptine or expectant management
• Pearl
Though the differential is broad and the evaluation extensive, three
processes top the list in all women with amenorrhea: pregnancy, pregnancy,
and pregnancy.
Reference
Pletcher JR et al: Menstrual disorders. Amenorrhea. Pediatr Clin North Am
1999;46:505. [PMTD: 1-384804]
+
Chapter 16 Gynecologic, Obstetric, & Breast Disorders 417
Urinary Incontinence
• Essentials of Diagnosis
• Uncontrolled loss of urine; classified as stress, urge, or overflow
• Stress incontinence: urine loss during coughing or exercising;
leakage observed on examination during cough or with Val sal va's
maneuver
• Urge incontinence due to spontaneous bladder contractions; accompanied
by urgency, associated with frequency and nocturia,
normal examination
• OverAow incontinence caused by overdistention of bladder; uncommon
in women, caused by neurologic lesion or outflow obstruction;
postvoid residual markedly elevated
• Evaluation indicated when diagnosis is uncertain or prior to surgical
correction
• Urinary tract infections commonly cause transient incontinence
or worsening of preexisting incontinence
• Differential Diagnosis
• Urinary tract infection
• Mobility disorders affecting ability to get to the toilet
• Neurologic causes as outlined above
• Urinary fistula, urethral diverticulum
• Medications: diuretics, anticholinergics, antihistamines, alphaadrenergic
blockers
• Treatment
• Exclude urinary tract infection
A voiding diary aids in diagnosis and guiding therapy
Kegel exercises, formal training of the pelvic muscles
For urge incontinence: timed voids, limit fluid intake and caffeine,
anticholinergic medications
Surgical treatment is effective in up to 85% for stress incontinence
refractory to conservative management
• Pearl
In older patients, be sure rectal sphincter tone is normal; this can be a
clue to a spinal cord lesion.
Reference
Keane DP et al: Urinary incontinence: anatomy, physiology and pathophysiology.
Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:207. [PMlD:
10897320]
17
Common Surgical Disorders
Abdominal Aortic Aneurysm
• Essentials of Diagnosis
• Overall incidence in patients over age 60 years is 2--6.5%
More than 90% originate below the renal arteries
Most asymptomatic, discovered incidentally at physical examination
or sonography
• Abdominal ultrasound has sensitivity approaching 100%
• Back or abdominal pain often precedes rupture
• Abdominal aortic aneurysm diameter is the most imponant predictor
of aneurysm rupture
• Most rupture leftward and posteriorly; left knee jerk may thus be
lost
• Generalized arteriomegaly in many patients
• Differential Diagnosis
• Pancreatic pseudocyst, pancreatitis
• Multiple myeloma
• Musculoskeletal causes of back pain
• Renal colic
• Bleeding peptic ulcer
• Treatment
• In asymptomatic patients, depending on age and presence of other
medical conditions, surgery is recommended when the aneurysm
is >5 cm
• Resection may be beneficial even for aneurysms as small as 4 cm
• In symptomatic patients, immediate repair irrespective of size
• Endovascular repair (transfemoral insertion of a prosthetic graft)
considered if the anatomy of aneurysm is suitable (ie, graft can
be secured infrarenally); long-term durability of endovascular
grafts is unknown
• Pearl
In upper gastrointestinal hemorrhage in patients over age 60 with a
normal upper endoscopy, consider aortoentericfistula.
Reference
Santilli JD et al: Diagnosis and treatment of abdominal aortic aneurysms. Am
Fam Physician 1997;56: 1081. [PMID: 9310060]
418
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 17 Common Surgical Disorders 419
+
Pharyngoesophageal Diverticulum
(Zenker's Diverticulum)
• Essentials of Diagnosis
• Most prevalent in the fifth to eighth decades of life
• Results from herniation of the mucosa through a weak point in
the muscle layer proximal to the cricopharyngeal muscle
• Dysphagia worsening as more is eaten; regurgitation of undigested
food, halitosis
• Gurgling sounds in the neck on auscultation
• Barium swallow confirms diagnosis by demonstrating the sac
• Differential Diagnosis
• Esophageal, mediastinal, or neck tumor
• Cricopharyngeal achalasia (occasionally associated)
• Esophageal web
• Achalasia or lower esophageal stricture
• Epiphrenic diverticulum (lower esophagus)
• Treatment
• There is no medical therapy; all patients should be considered
candidates for surgical treatment
• Pearl
Unsuspected Zenker's diverticulum may be inadvertently pelforated at
upper endoscopy, a reason to peiform contrast radiography prior to
esophagoduodenoscopy.
Reference
Sideris L et al: The treatment of Zenker's diverticula: a review. Semin Thorac
Cardiovasc Surg 1999;11 :337. [PMID: 10535375]
+
420 Essentials of Diagnosis &Treatment
Malignant Tumors of the Esophagus
• Essentials of Diagnosis
• Progressive dysphagia-initially during ingestion of solid foods,
later with liquids; progressive weight loss ominous
• Smoking, alcohol, asbestos, gastToesophageal reAux disease are
risk factors
• Classic radiographic appearance with irregular mucosal pattern
and narrowing, with shelf-like upper border or concentrically narrowed
esophageal lumen
• CT scan delineates extent of disease
• Adenocarcinoma (often associated with reAux-induced Barrett's
esophagus) now has incidence similar to that of squamous cell
• Differential Diagnosis
• Benign tumors of the esophagus « 1%)
• Benign esophageal stricture
• Esophageal diverticulum
• Esophageal webs
• Achalasia (may be associated)
• Globus hystericus
• Treatment
• In 75-80% of patients, local tumor invasion or distant metastasis
at the time of presentation precludes cure
• For patients with localized primary, resection (when feasible) provides
the best palliation
• Adjuvant chemotherapy with radiation therapy or surgical resection
results in cure for only 10-15%
• Expandable metallic stent placement, laser fulguration, feeding
tube placement with or without radiation therapy for additional
palliation
• Pearl
True dysphagia-food sticking upon swallowing-has nearly 100%
association with anatomic lesions.
Reference
Fox JR et al: Today's approach to esophageal cancer. What is the role of the primary
care physician? Postgrad Med 2000; I07: J09. [PMID: J08444946]
Chapter 17 Common Surgical Disorders 421
+
Obstruction of the Small Intestine
• Essentials of Diagnosis
• Defined as partial or complete obstruction of the intestinal lumen
by an intrinsic or extrinsic lesion
• Etiology: adhesions (eg, from prior surgery or pelvic inflammatory
disease) 60%, malignancy 20%, hernia 10%, inflammatory
bowel disease 5%, volvulus 3%, other 2%.
• Crampy abdominal pain, vomiting (often feculent in complete
obstruction), abdominal distention, constipation or obstipation
• Distended, tender abdomen with or without peritoneal signs;
high-pitched tinkling or peristaltic rushes audible
• Patients often intravascularly depleted secondary to emesis, decreased
oral intake, and sequestration of fluid in the bowel wall
and lumen and the peritoneal cavity
• Plain films of the abdomen show dilated small bowel with more
than three air-fluid levels
• Differential Diagnosis
• Adynamic ileus due to any cause (eg, hypokalemia, pancreatitis,
nephrolithiasis, recent operation or trauma)
• Colonic obstruction
• Intesti nal pseudo-obstruction
• Treatment
• Nasogastric suction
• Fluid and electrolyte (especially potassium) replacement with isotonic
crystalloid
• Most management decisions are based on the distinction between
partial and complete obstruction
• Surgical exploration for suspected hernia strangulation, or obstruction
not responsive to conservative therapy
• Pearl
Altlwugh Osler referred to adhesions as "the refuge of the diag/wstically
destitute, " they remain the nwst common cause of small bowel
obstruction.
Reference
Wilson MS et al: A review of the management of small bowel obstruction. Members
of the Surgical and Clinical Adhesions Research Study (SCAR). Ann R
Call Surg Engl 1999;81:320. [PMID: 10645174]
+
422 Essentials of Diagnosis & Treatment
Functional Obstruction
(Adynamic Ileus, Paralytic Ileus)
• Essentials of Diagnosis
• History of precipitating factor (eg, recent surgery, peritonitis,
other serious medical illness, anticholinergic dmgs, hypokalemia)
• Continuous abdominal pain, distention, vomiting, and obstipation
• Minimal abdominal tenderness; decreased to absent bowel sounds
• Radiographic images show diffuse gastrointestinal organ distention
• Differential Diagnosis
• Mechanical obstruction due to any cause
• Specific diseases associated with functional obstruction (ie, perforated
viscus, pancreatitis, cholecystitis, appendicitis, nephrolithiasis)
• Colonic pseudo-obstruction (Ogilvie's syndrome)
• Treatment
• Restriction of oral intake; nasogastric suction in severe cases
• Attention to electrolyte and fluid imbalance (ie, hypokalemia,
dehydration)
• Prokinetic drugs (metoclopramide, erythromycin) may be tried
• Laparotomy should be avoided if at all possible to avert the subsequent
risk of mechanical obstruction from adhesions
• Pearl
Lower lobe pneumonia may on occasion cause adynamic ileus.
Reference
Dorudi Set al: Acute colonic pseudo-obstruction. Sr ] Surg 1992;79:99. [PMID:
1555081 ]
Chapter 17 Common Surgical Disorders 423
Acute Appendicitis
+
• Essentials of Diagnosis
• Consider in all patients with unexplained abdominal pain; 6% of
the population will have appendicitis in their lifetime
Anorexia invariable
• Abdominal pain, initially poorly localized or periumbilical, then
localizing to the right lower quadrant over 4-48 hours in twothi
rds of patients
• Abdominal plain films and pattern of bowel function are of little
diagnostic value
• Low-grade fever, right lower quadrant tenderness at McBurney's
point with or without peritoneal signs
• Pelvic and rectal examinations are critically important
• Mild leukocytosis (l0,000-18,000/!lL) with PMN predominance;
microscopic hematuria or pyuria is common
• Consider pelvic ultrasound (in women) and CT scan to differentiate
surgical from nonsurgical pathologic conditions
• Differential Diagnosis
• Gynecologic pathology (eg, ectopic pregnancy, pelvic inflammatory
disease, endometriosis, mittelschmerz, twisted ovarian cyst)
• Urologic pathology (eg, testicular torsion, acute epididymitis)
Nephrolithiasis
Urinary tract infection or pyelonephritis
Perforated peptic ulcer
• Inflammatory bowel disease
• Meckel's diverticulitis
• Mesenteric adenitis
• Acute cholecystitis
• Right lower lobe pneumonia
• Treatment
• Open or laparoscopic appendectomy
• Certainty in diagnosis remains elusive (10-30% of patients are ~
found to have a normal appendix at operation)
• When diagnosis unclear, observe for several hours with serial
examinations, or (if the patient is reliable) schedule return in
8-12 hours for reevaluation
• Pearl
The most common cause ofthe acute abdomen in every decade oflife.
Reference
Hardin DM Jr: Acute appendicitis: review and update. Am Fam Physician
1999;60:2027. [PMlD: 10569505]
+
424 Essentials of Diagnosis &Treatment
Diverticulitis
• Essentials of Diagnosis
• Acute, intermittent cramping left lower abdominal pain; constipation
in some cases alternating with diarrhea
• Fever, tenderness in left lower quadrant, with palpable abdominal
mass in some patients
• Leukocytosis
Radiographic evidence ofdiverticula, thickened interhaustral folds,
narrowed lumen
• CT scan is the safest and most cost-effective diagnostic method
• Differential Diagnosis
• Colorectal carcinoma
• Appendicitis
• Strangulating colonic obstruction
• Colitis due to any cause
• Pelvic inflammatory disease
• Ruptured ectopic pregnancy or ovarian cyst
• Inflammatory bowel disease
• Treatment
• Liquid diet (10 days) and oral antibiotics (metronidazole plus
ciprofloxacin or trimethoprim-sulfamethoxazole) for mild first
attack
• Nasogastric suction and broad-spectrum intravenous antibiotics
for patients requiring hospitalization (eg, failed outpatient management,
inadequate analgesia)
• Percutaneous catheter drainage for intra-abdominal abscess
• Emergent laparotomy with colonic resection and diversion for
generalized peritonitis, uncontrolled sepsis, visceral perforation,
and acute clinical deterioration
• High-residue diet, stool softener, psyllium mucilloid for chronic
therapy
• Pearl
Left-sided diverticula are more common and more likely to become
inflamed; right-sided diverticula are less common and more likely to
bleed.
Reference
Ferzoco LB et al: Acute diverticulitis. N Engl J Med 1998;338:1521. [PMID:
9593792]
Chapter 17 Common Surgical Disorders 425
Pancreatic Pseudocyst
+
• Essentials of Diagnosis
• Collection of pancreatic fluid in or around the pancreas; may occur
as a complication of acute or chronic pancreatitis
• Characterized by epigastric pain, tenderness, fever, and occasionally
a palpable mass
• Leukocytosis, persistent serum amylase elevation
• Pancreatic cyst demonstrated by CT scan
• Complications include hemorrhage, infection, rupture, fistula formation,
pancreatic ascites, and obstruction of surrounding organs
• Differential Diagnosis
• Pancreatic phlegmon or abscess
• Resolving pancreatitis
• Pancreatic carcinoma
• Abdominal aortic aneurysm
• Treatment
• up to two-thirds spontaneously resolve
Avoidance of alcohol
• Percutaneous catheter drainage with nutritional support while
avoiding oral feedings effective in many cases
Decompression into an adjacent hollow viscus (cystojejunostomy
or cystogastrostomy) may be necessary
Octreotide to inhibit pancreatic secretion
• Pearl
There are only two causes of pulsatile abdominal masses: pancreatic
pseudocyst and aneurysm.
Reference
Lillemoe KD et al: Management of complications of pancreatitis. Curr Probl
Surg 1998;35: I. [PMID: 9452408] III
+
426 Essentials of Diagnosis & Treatment
Hernia
• Essentials of Diagnosis
• Protrusion of a viscus through an opening in the wall of the cavity
in which it is contained (sac is an outpouching of peritoneum)
• Lump or swelling in the groin, sometimes associated with sudden
pain and bulging during heavy lifting or straining
• Discomfort is worse at the end of the day, relieved when patient
reclines and hernia reduces
• Clinically distinguishing an indirect from a direct hernia is unimportant,
since their operative repair is the same
Early symptoms of incarceration are those of partial bowel obstruction;
the early discomfort will be periumbilical
• A femoral hernia is an acquired protrusion of a peritoneal sac
through the femoral ring; smaller, more difficult to palpate and to
diagnose
• Differential Diagnosis
• Hydrocele
• Varicocele
• Inguinallymphadenopathy
• Lipoma of the spermatic cord
• Testicular torsion
• Femoral artery aneurysm
• Treatment
• In general, aJ I hernias should be repaired unless local or systemic
conditions preclude a safe outcome
Elective outpatient surgical repair for reducible hernias
• Attempt reduction of incarcerated (irreducible) hernias (when
peritoneal signs are absent) with conscious sedation, Trendelenburg
position, and steady, gentle pressure
Emergent repair for nomeducible, incarcerated, or strangulated
• Pearl
The patient tells you he has an inguinal hemia; you tell him he has a
femoral hernia.
Reference
Avisse C et al: The inguinal rings. Surg Clin North Am 2000;80:49. [PMID:
10685144]
Chapter 17 Common Surgical Disorders 427
Intestinal Ischemia
+
• Essentials of Diagnosis
Acute:
• Causes are emboli (eg, in atrial fibrillation); thrombosis (eg, in
patients with atherosclerosis), or nonocclusive insufficiency (eg,
in congestive heart failure)
• With occlusion, diffuse abdominal pain but minimal physical
findings
• Lactic acidosis suggests bowel infarction rather than ischemia
Chronic:
• Results from atherosclerotic plaques of superior mesenteric,
celiac axis, and inferior mesenteric; more than one of the above
major arteries must be involved because of collateral circulation
• Epigastric or periumbilical postprandial pain; patients limit intake
to avoid pain, resulting in weight loss and less prominent pain
Ischemic colitis:
• Occurs primarily with inferior mesenteric artery ischemia; episodic
bouts of crampy lower abdominal pain and mild, often
bloody diarrhea; lactic acidosis or colonic infarction rare
• Differential Diagnosis
• Diverticulitis and appendicitis
• Myocardial infarction
Pancreatitis
• Inflammatory bowel disease and colitis due to other causes
• Visceral malignancy
• Polyarteritis nodosa
• Renal colic
• Cholecystitis
• Treatment
• Decision to operate is challenging given comorbidities
• Laparotomy with removal of necrotic howel
• Pre- and postoperative intra-arterial infusion of papaverine if
occlusion is embolic
• Pearl
Abdominal pain in a patient with heart failure receiving digitalis and
diuretics is nOllOcclusive mesenteric ischemia until proved to be otherwise.
Reference
Brandt LJ et al: AGA technical review on intestinal ischemia. American Gastrointestinal
Association. Gastroenterology 2000;118:954. [PMID: 10784596]
+
428 Essentials of Diagnosis & Treatment
Acute Cholecystitis
• Essentials of Diagnosis
• Acute, steady right upper quadrant or midabdominal pain; nausea,
food intolerance common
• Classic finding is Murphy's sign, which refers to inspiratory arrest
with palpation in the right upper quadrant
• Fever, leukocytosis, slight elevation in liver function studies,
amylase, and lipase
• Biliary colic and acute cholecystitis often overlap; clinical distinction
may be difficult
• Abdominal ultrasound is the diagnostic procedure of choice, showing
stones, ductal anatomy, and inflammation (thickened gallbladder
wall and pericholecystic fluid); may be acalculous
• Radionuclide (HillA) scan shows a nonopacified gallbladder and
diagnoses acute cholecystitis accurately in 97% of cases
• Differential Diagnosis
• Acute appendicitis
• Acute pancreatitis
• Peptic ulcer disease
• Acute hepatitis
• Right lower lobe pneumonia
• Myocardial infarction
• Radicular pain in thoracic dermatome, eg, preeruptive zoster
• Treatment
• Bowel rest, intravenous fluids, and analgesics; give parenteral
antibiotics to cover coliform organisms
• Early laparoscopic cholecystectomy leads to reduced morbidity
and mortality
• Immediate cholecystectomy for gall bladder ischemia, perforation,
emphysematous cholecystitis; percutaneously placed cholecystostomy
catheters used initially in severely ill or elderly patients
with high surgical risk
• Endoscopic retrograde cholangiopancreatography (ERCP) with
sphincterotomy should be performed when there are associated
common bile duct stones, pancreatitis, or cholangitis
• Pearl
In cholecystitis, the patient precisely identifies the time ofonset ofsymptoms-
not so in appendicitis.
Reference
Hashizume M et al: The clinical management and results of surgery for acule
cholecystitis. Semin Laparosc Surg 1998;5:69. [pMID: 8259091]
Chapter 17 Common Surgical Disorders 429
Carotid Artery Disease
+
• Essentials of Diagnosis
• Most common in patients with standard risk factors for atherosclerosis
(eg, hypertension, hypercholesterolemia, diabetes mellitus)
• Many patients asymptomatic
• Otherwise, amaurosis fugax; transient hemiparesis with or without
aphasia or sensory changes; stroke diagnosed if focal findings
persist for more than 24 hours
• Bruit may be present but correlates poorly with degree of stenosis
• Duplex ultrasound useful in assessing stenosis; gadolinium angiography
demonstrates anatomy
• Differential Diagnosis
• Carotid artery dissection
• Giant cell arteritis
• Takayasu' s arteritis
• Lipohyalinosis
• Radiation fibrosis
• Cardiac emboli
• Brain tumor or abscess (in patient with stroke)
• Treatment
• Aspirin
• Thromboplastic agents in highly selected patients with cerebral
ischemia: less than 3 hours of symptoms, no hemorrhage on CT
• Carotid endarterectomy in stenosis> 70% with or without
symptoms
• Surgery of uncertain benefit when stenosis < 70%
• Pearl
Only one in four untreated patients with> 70% stenosis will have a
stroke; of patients found to have J00% occlusion, only half have suF
fered a neurologic event.
Reference
Biller] et al: When to operate in carotid artery disease. Am Pam Physician
2000;61 :400. [PMID: 10670506] -
+
430 Essentials of Diagnosis & Treatment
Acute lower Extremity Arterial Occlusion
• Essentials of Diagnosis
• Typical patient has valvular hypertensive or ischemic heart disease,
often peripheral vascular disease as well
• Some occur following posterior knee dislocation, iatTogenic catheter
injury
• Abrupt onset of pain, dysesthesia
• Pulses absent, limb cold; occasional atrial fibrillation on cardiac
examination
• Leukocytosis; elevated CK and LDH
• Differential Diagnosis
• Neuropathic pain
• Deep venous thrombosis
• Reflex sympathetic dystrophy
• Systemic vasculitis
• Cholesterol atheroembolic syndrome
• Treatment
• Embolectomy, either surgically or by Fogarty catheter
• Fasciotomy if compartment syndrome complicates
• Heparin if limb judged not to be threatened; occasionally, vasospasm
gives false impression of total occlusion, and heparin may
help
• Pearl
In a patient with an intra-arterial femoral line in the leu on a ventilator,
there will be no history-check distal pulses frequently.
Reference
Thrombolysis in the management of lower limb peripheral arterial occlusiona
consensus document. Working Party on Thrombolysis in the Management
of Limb lschemia. Am J CardioI1998;81:207.lPMlD: 9591906J
18
Common Pediatric Disorders*
Croup
• Essentials of Diagnosis
• Viral croup, usually due to parainfluenza virus, affects younger
children
• Barking cough, stridor, and hoarseness following upper respiratory
infection
Usually worse at night
Lateral neck films can be useful diagnostically; patients with
viral croup have subglottic narrowing (steeple sign) and a normal
epiglottis
• Direct laryngoscopy rules out epiglottitis or laryngomalacia in
confusing cases but must be performed cautiously with anticipation
of intubation
• Differential Diagnosis
• Angioneurotic edema
Foreign body in the esophagus or larynx
Retropharyngeal abscess
Epiglottitis
Laryngomalacia
• Treatment
• Treatment of viral croup is supportive; mist therapy is anecdotal
• Oral hydration, oxygen, racemic epinephrine, and corticosteroids
are accepted therapy
• Most croup is self-limited and lasts less than 5 days
• Pearl
Every mother knows that a walk with a child in the cool night air is the
treatment ofchoice.
Reference
Klassen TP: Croup. A current perspective. Pediatr Clin North Am 1999;46: 1167.
[PMID: 10629679]
* The following common childhood diseases are discussed in other chapters:
aspiration of foreign body and cystic fibrosis, Chapter 2; pharyngitis, mumps,
poliomyelitis, varicella and zoster, infectious mononucleosis, rabies, and rubella,
Chapter 8; appendicitis, Chapter 16; otitis media and otitis externa, Chapter 19.
431
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
432 Essentials of Diagnosis & Treatment
Pyloric Stenosis
• Essentials of Diagnosis
• Increase in size of the muscular layer of the pylorus of unknown
cause; occurs in one or two out of 1000 births, with males and
whites affected more commonly
• Vomiting beginning between 2-8 weeks of age; may become
projectile; rarely bilious
• Infant is hungry and nurses avidly, but weight gain is poor and
growth retardation occurs
• Constipation, dehydration, and hypochloremic alkalosis with
hypokalemia are typical
• Palpable olive-sized mass in the subhepatic region best felt after
the child has vomited
• String sign and retained gastric contents on upper gastrointestinal
series; ultrasound shows a hypoechoic mass
• Differential Diagnosis
• Gastroesophageal reflux disease
• Esophageal stenosis or achalasia
• Small bowel obstruction due to other causes
• Antral web
• Adrenal insufficiency
• Pylorospasm
• Other causes of growth retardation
• Treatment
• Pyloromyotomy is the treatment of choice
• Dehydration and electrolyte abnormalities should be corrected
prior to surgery
• Excellent prognosis after surgery
• Pearl
Pyloric stenosis: an epigastric mass in a vomiting baby with a hard
metabolic alkalosis? Game, set, and match for this diagnosis.
Reference
Dinkevich E et al: Pyloric stenosis. Pediatrics in Rev 2000;21:249. [PMlD:
10878190]
Chapter 18 Common Pediatric Disorders 433
Down's Syndrome
+
• Essentials of Diagnosis
• Occurs in I :600 newborns, with increasing incidence in children
of mothers over 35 years of age
• Ninety-five percent of patients have 47 chromosomes with trisomy
21
• Characteristic findings are small, broad head, flat nasal bridge,
upward slanting palpebral fissures, transverse palmar crease, short
hands, and inner epicanthal folds
• One-third to one-half have congenital heart disease; atlantoaxial
subluxation and sensorineural hearing loss more frequent than in
the general population; leukemia is 20 times more common, and
there is an increased susceptibility to infections
• Differential Diagnosis
• The chromosome and phenotypic abnormalities are pathognomOnic
• Treatment
• Goal of therapy is to help affected patients develop full potential
• No convincing evidence exists to support any of the forms of general
therapy that have been advocated (eg, megadoses of vitamins,
exercise programs)
• Therapy directed toward specific problems (eg, cardiac surgery,
antibiotics)
• Electrocardiography and echocardiography in the neonatal period,
yearly vision and hearing examinations, yearly thyroid screening,
and a cervical spine x-ray once during the preschool years
• Pearl
Chromosome 21 codes the beta-amyloid seen ubiquitously in brains of
Down's patients and Alzheimer's in adults.
Reference
Saenz RB: Primary care of infants and young children with Down syndrome.
Am Fam Physician 1999;59:381. [PMID: 99301301
+
434 Essentials of Diagnosis &Treatment
Respiratory Syncytial Virus (RSV) Disease
• Essentials of Diagnosis
• The most important cause of lower respiratory tract illness in young
children, causing half of aJi cases of bronchiolitis and many cases
of pneumonia
• Epidemics in late faJi to early spring; attack rates are high
• The classic disease (bronchiolitis) is characterized by diffuse
wheezing, difficulty feeding, variable fever, cough, tachypnea,
and inspiratory retractions
• Apnea may be the presenting symptom, especially in premature
infants
• Chest x-ray shows hyperinflation and peribronchiolar thickening,
occasionaJlyatelectasis
• RSV antigen detected in nasal or pulmonary secretions in most
• Differential Diagnosis
• Bronchiolitis due to other viruses or bacteria
• Asthma
• Foreign body aspiration
• Chlamydial pneumonitis
• Pertussis
• Laryngomalacia
• Substernal goiter
• Treatment
• Severely iJi children should be hospitalized, given humidified
oxygen, and kept in respiratory isolation
• Bronchodilator therapy usually instituted
• Corticosteroid use considered in hospitalized patients
• Ribavirin, by continuous aerosolization; given to selected patients
at very high risk.
• Pearl
Consid.er RSV ifcroup lastsfor d.ays to weeks.
Reference
Malhotra A et al: Influenza and respiratory syncytial virus. Update on infection,
management, and prevention. Pediatr Clin North Am 2000;47:353. [PMlD:
10761508]
Chapter 18 Common Pediatric Disorders 435
+
Roseola Infantum (Exanthema SUbitum)
• Essentials of Diagnosis
• A benign illness typically caused by human herpes virus 6 occurring
primarily in children 3 months to 4 years of age; 90% of
cases occur before the second year
• Abrupt onset of fever (as high as 40°C) lasting up to 5 days in an
otherwise mildly ill child; dissociation between systemic symptoms
and febrile course
• Fever ceases abruptly; a characteristic rash develops in 20%, consisting
of rose-pink maculopapules beginning on the trunk and
spreading outward with disappearance in 1-2 days
• No conjunctivitis or pharyngeal exudate, but there may be mild
cough or coryza
• Rash may occur without fever
• Differential Diagnosis
• Serious bacterial infections
• Drug aJ lergy
• Measles
• Rubella
• Enterovirus infection
• Scarlet fever
• Toxic shock syndrome
• Kawasaki disease
• Treatment
• Supportive care only; acetaminophen and sponge baths for fever
• Reassurance for parents
• Febrile seizures occur, but no more commonly than with other
self-limited infections
• Children are no longer infectious once they are afebrile
• Pearl
No other illness exhibits rash after defervescence.
Reference
Leach CT: Human herpesvirus-6 and -7 infections in children: agents of roseola
and other syndromes. Curr Opin Pediatr 2000;12:269. [PMID: 10836165]
+
436 Essentials of Diagnosis &Treatment
Acute lymphoblastic leukemia (All)
• Essentials of Diagnosis
• The most common malignancy of childhood; peak age at onset is
4 years; accounts for 75% of childhood leukemias
• Uncontrolled proliferation of immature lymphocytes
• Intermittent fever, bone pain, petechiae, purpura, pallor; hepatosplenomegaly
and lymphadenopathy unusual
• Single or multiple cytopenias common; serum uric acid and LDH
often elevated
• Bone marrow shows homogeneous infiltration of more than 25%
of leukemic blasts; most have blasts expressing common ALL
antigen (CALLA)
• Differential Diagnosis
• EBV of CMV infection
• Immune thrombocytopenic purpura
• Autoimmune hemolytic anemia
• Aplastic anemia
• Juvenile rheumatoid arthritis
• Pertussis
• Other malignancies
• Treatment
• Induction therapy (first month of therapy), usually with three or
four drugs, including prednisone, vincristine, asparaginase, daunorubicin,
or methotrexate
• Consolidation phase: intrathecal chemotherapy and sometimes
cranial irradiation to treat Iymphoblasts that may be present in
meninges
• Delayed intensification to further reduce leukemic cells
• Maintenance therapy with mercaptopurine, weekly methotrexate,
and monthly vincristine or prednisone
• Bone marrow transplant considered in relapsed patients
• Children with white counts under 50,000/~L at diagnosis or between
I year and j 0 years of age have better prognosis
• Those with mediastinal mass or chromosomal translocations have
a worse prognosis
• Over 70% of treated patients are cured
• Pearl
"Spontaneous cures" of ALL in old.er literature are likely cases of
severe infectious mononucleosis.
Reference
Pui CH et al: Acute lymphoblastic leukemia. N Engl J Med 1998;339:605.
[PMJD: 971838 J]
Chapter 18 Common Pediatric Disorders 437
+
Wilms' Tumor (Nephroblastoma)
• Essentials of Diagnosis
• A renal tumor representing 6% of cancers in patients under age 15;
peak age at diagnosis is 3
• Occurs sporadically or as part of a malformation syndrome or
cytogenic abnormality
• Asymptomatic abdominal mass (80%), fever (25%), and hematuria
(20%)
• Five to 10 percent are bilateral
• Hypertension, genitourinary abnormalities, aniridia, hemihypertrophy
occasionally seen
• Abdominal ultrasound or CT reveals a solid intrarenal mass; 10%
of patients will have metastatic disease (lung or liver) at time of
diagnosis; ultrasound and chest x-ray may help show spread of
metastases
• Differential Diagnosis
• Neuroblastoma originating from the adrenal
• Other abdominal tumors
• Polycystic kidneys
• Renal abscess
• Hydronephrosis
• Treatment
• Once the diagnosis is made, almost all patients undergo surgical
exploration of the abdomen with attempted excision of the tumor
and possible nephrectomy
• Vincristine and dactinomycin routinely used in all patients; doxorubicin
administered in those with advanced disease
• Flank irradiation effective in some patients, and lung irradiation
may be used to treat metastases
• Pearl
Along with neuroblastoma, a commonly curable tumor once uniformly
fatal.
Reference
Petruzzi MJ et al: Wilms' tumor. Pediatr Clin North Am 1997;44:939. [PMlD:
9286293] -
+
438 Essentials of Diagnosis & Treatment
Juvenile Rheumatoid Arthritis (Still's Disease)
• Essentials of Diagnosis
Three types: pauciarticular, polyarticular, systemic:
• Pauciarticular: fewer than five joints involved; younger females
can have uveitis, knee involvement, ANA-positivity; adolescents,
usually male, have both large and small joint disease, rarely ANApositive
• Polyarticular: five or more joints, occurs at any age; fever and
weight loss common; ANA and rheumatoid factor positive in
older children
• Systemic: any age; fever and rash common, with lymphadenopathy,
hepatosplenomegaly, pericarditis, and pleuritis; joint
symptoms variable, often follow systemic symptoms by weeks to
months; rheumatoid factor and ANA routinely negative
• Differential Diagnosis
• Rheumatic fever
• Infective arthritis
• Reactive arthritis due to various causes
• Lyme disease
• SLE
• Dermatomyositis
• Leukemia
• InAammatory bowel disease
• Bone tumors
• Osteomyelitis
• Treatment
• Goals of treatment are to restore function, relieve pain, and maintain
joint function
• NSAIDs and physical therapy are the mainstays
• Methotrexate, hydroxychloroquine, sulfasalazine, gold salts, and
local corticosteroid injections for those symptomatic after NSATDs
• For the most refractory cases, systemic steroids may be required
• Pearl
Systemic Still's disease is one of the few causes of biquotidian fever
spikes.
Reference
Woo Pet al: Juvenile chronic arthritis. Lancet 1998;351 :969. [PMID: 9734957]
Chapter 18 Common Pediatric Disorders 439
Colic
+
• Essentials of Diagnosis
• A syndrome characterized by severe and paroxysmal crying that
usually worsens in the late afternoon and evening
• Abdomen sometimes distended, the facies can be pained, fists are
often clenched, infant is unresponsive to soothing
• Thought to be due to a disturbance in the gastrointestinal tract,
but unproved
• Begins in the first few weeks of life and peaks at 2-3 months; may
last into the fifth month of life
• Differential Diagnosis
• Normal crying in an infant
• Any illness in the infant causing distress, such as otitis media,
intestinal cramping, corneal abrasion
• Food allergy
• Treatment
• Reassurance of parents
• Education of the parents regarding the baby's cues
• Phenobarbital elixir and dicyclomine not recommended
• Elimination of cow's milk from the formula (or from the mother's
diet if she is nursing) in refractory cases to rule out milk protein
allergy
• Hypoallergenic diet, soy formula, reduced stimulation may help
in difficult cases
• Pearl
Rule of Threes: During the first 3 months, a healthy infant cries more
than 3 hours a day,for more than 3 days a week,for more than 3 weeks.
Reference
Balon AJ: Management of infantile colic. Am Pam Physician 1997;
55:235. [PMlD: 9012281]
+
440 Essentials of Diagnosis & Treatment
Tetralogy of Fallot
• Essentials of Diagnosis
• The most common cyanotic heart disease after I week of age
• Ventricular septal defect, obstruction to right ventricular outflow,
right ventricular hypertrophy, and overriding aorta
Varying cyanosis after the neonatal period, dyspnea on exertion,
easy fatigability, growth retardation
Right ventricular lift, systolic ejection murmur (rough) maximal
at the left sternal border, single loud S2
• Elevated hematocrit, boot-shaped heart on chest x-ray
• Echocardiography, cardiac catheterization, and angiocardiography
all useful in confirming the diagnosis
• Differential Diagnosis
Other cymwtic heart diseases:
• Pulmonary atresia with intact ventricular septum
• Tricuspid atresia
• Hypoplastic left heart syndrome
• Complete transposition of the great arteries
• Total anomalous pulmonary venous return
• Persistent truncus arteriosus
• Treatment
• Acute treatment of cyanotic episodes includes supplemental oxygen,
placing the patient in the knee-chest position; consideration
of intravenous propanolol, morphine
• Palliation with oral beta-blockers or surgical anastomosis between
a systemic artery and the pulmonary artery (Blalock-Taussig shunt)
recommended for very small infants with severe symptoms and in
those who are not candidates for complete correction
• Total surgical correction (ventricular septal defect closure and
right ventricular outflow tract reconstruction) is the treatment of
choice in selected patients; patients are still at risk for sudden
death because of arrhythmias
• Complete repair in childhood has a IO-year survival rate of more
than 90% and a 30-year survival rate of 85%
• Pearl
The combination of right ventricular hypertrophy, small pulmonary
arteries, and pulmonary oligemia is seen in no other condition.
Reference
Waldman JO et al: Cyanotic congenitall1eart disease with decreased pulmonary
blood flow in children. Pediatr Clin North Am 1999;46:385. [PMID:
10218082]
Chapter 18 Common Pediatric Disorders 441
+
Kawasaki Disease
(Mucocutaneous Lymph Node Syndrome)
• Essentials of Diagnosis
• Illness of unknown cause characterized by 5 days of fever, nonexudative
conjunctivitis, inflamed oral mucous membranes, cervicallymphadenopathy
of at least 1.5 cm, rash over the trunk and
extremities, and edema
• Cardiovascular complications include myocarditis, pericarditis,
and arteritis predisposing to coronary artery aneurysm formation
• Acute myocardial infarction may occur; 1-2% of patients die
from this during the initial phase of the disease
• Arthritis, thrombocytosis, and elevated sedimentation rate commonly
seen
• Differential Diagnosis
• Acute rheumatic fever
• Juvenile rheumatoid arthritis
• Viral exanthems
• Infectious mononucleosis
• Streptococcal pharyngitis
• Measles
• Toxic shock syndrome
• Treatment
• Patients require an echocardiogram to evaluate for coronary
aneurysms
• Intravenous immune globulin and high-dose aspirin are the mainstays
of therapy
• Corticosteroids contraindicated
• Pearl
This and anomalous origin of a coronary artery from the pulmonary
artery are the sole causes ofQ wave infarction in childhood.
Reference
Taubert KA et al: Kawasaki disease. Am Fam Physician 1999;59:3093. [PMID:
10392592]
+
442 Essentials of Diagnosis &Treatment
Bacterial Meningitis
• Essentials of Diagnosis
• Signs of systemic illness (fever, malaise), headache, stiff neck,
and altered mental status
• In infants under 12 months of age, such signs of meningeal irritation
may be absent
• Predisposing factors can include ear infection, sinusitis, recent
neurosurgical procedures, and skull fracture
No symptom or sign reliably distinguishes bacterial cause from
meningitis due to viruses, fungi, or other pathogens
• Organisms depend upon the age: < 1 month, group B or D streptococci,
Enterobacteriaceae, listeria; 1-3 months, above pathogens
plus Haemophilus injluenzae, pneumococci, and meningococci;
3 months to 7 years, H injluenzae, pneumococci, and meningococci
• Cerebrospinal fluid typically shows elevated protein, low glucose,
elevated WBC (> 1000/,uL) with a high proportion ofPMNs
(> 50%)
• Gram stain and culture often lead to the definitive diagnosis
• Differential Diagnosis
• Meningitis due to nonbacterial organisms
Brain abscess
• Encephalitis
• Sepsis without meningitis
• Intracranial mass or hemorrhage
• Treatment
• Prompt empiric antibiotics can be life-saving
• Exact antibiotic regimen depends upon age of patient; therapy
narrowed once the susceptibilities of the organism known
• Concomitant dexamethasone decreases morbidity and mortality
• Patients monitored for acidosis, syndrome of inappropriate secretion
of vasopressin, and hypoglycemia
• Coagulopathies may require platelets and fresh frozen plasma
• Mortality can be up to 20% in neonates, and neurologic sequelae
may occur in up to 25% of affected patients
• Pearl
When bacteria cannot be seen on Gram stain of cerebrospinal jluid in
subsequently proved meningitis, meningococcus is the most likely cause.
Reference
Pong A et al: Bacterial meningitis and the newborn infant. Infect Dis Clin North
Am 1999;13 :711. [PMTD: 10470563]
Chapter 18 Common Pediatric Disorders 443
+
Henoch-SchOnlein Purpura (Anaphylactoid Purpura)
• Essentials of Diagnosis
• A small-vessel vasculitis affecting skin, gastrointestinal tract, and
kidney
• Occurs slighdy more often in males under 10 years of age; twothirds
have a preceding upper respiratory tract infection; occasionally
observed in adults
• Skin lesions often begin as urticaria and progress to a maculopapular
eruption, finally becoming a symmetric purpuric rash
• Eighty percent develop migratory polyarthralgias or polyarthritis;
edema of the hands, feet, scalp, and periorbital areas occurs
commonly
• Colicky abdominal pain occurs in two-thirds; renal involvement
in 25-50%
• Platelet count, prothrombin time, and partial thromboplastin time
nonnal; urinalysis may reveal hematuria and proteinuria; serum
IgA often elevated
• Differential Diagnosis
• Immune thrombocytopenic purpura
• Meningococcemia
• Rocky Mountain spotted fever
• Other hypersensitivity vasculitides
• Juvenile rheumatoid arthritis
• Kawasaki disease
• Leukemia
• Child abuse
• Treatment
• Pain medications and NSAIDs to treat joint pain and inflammation
• Corticosteroid therapy for symptomatic relief; does not alter skin
or renal manifestations
• No satisfactory specific treatment
• Prognosis is generally good
• Pearl
Remember this diagnosis in adults with abdominal pain and palpable
purpura-although it is mostly a pediatric problem.
Reference
Saulsbury Fr: Henoch-SchOnlein purpura in children. Repon of 100 patients and
review of the literature. Medicine (Baltimore) 1999;78:395. [PMID: 10575422]
III
+
444 Essentials of Diagnosis &Treatment
Intussusception
• Essentials of Diagnosis
• The telescoping of one part of the bowel into another, leading to
edema, hemorrhage, ischemia, and eventually infarction
• Peak is between 6 months and I year of age; intussusception is the
most common cause of intestinal obstruction in the first 2 years
of life
Lead points can include hypertrophied Peyer patches, polyps,
lymphoma, or other tumors; in children over 6, lymphoma most
common lesion
Most (90%) are ileocolic; ileoileal, colocolic also
• Symptoms include intermittent colicky abdominal pain, vomiting,
and (late) bloody stool
• Plain films may show signs of obstruction, but a barium or airbarium
enema is the standard for diagnosis
• Differential Diagnosis
• Volvulus
• Incarcerated hernia
• Acute appendicitis
• Acute gastroenteritis
• Urinary tract infection
• Small bowel obstruction due to other cause
• Renal calculus
• Pancreatitis
• Perforated viscus
• Treatment
• Patients stabilized with fluid; decompressed with a nasogastric tube
• Surgical consultation to exclude perforation
• Air-barium enema has a reduction rate of up to 90%, but never
performed if perforation is suspected
• Reduction hy enema may result in perforation as much as 1% of
the time
• If perforation occurs or if enema fails, surgical decompression
may be necessary
• Recurs in up to 10% ofcases, usually in the first day after reduction
• Pearl
Recurrent intussusception suggests the diagnosis ofPeutz-Jeghers "yndrame.
Reference
Winslow BT et al: Intussusception. Am Fam Physician 1996;54:213. [PMID:
8677837]
Chapter 18 Common Pediatric Disorders 445
Otitis Media
+
• Essentials of Diagnosis
• Peak incidence between the ages of 6 months and 3 years
• History may include fever, ear pain, and other nonspecific systemic
symptoms
• Tympanometry shows an opaque, bulging, hyperemic tympanic
membrane with a loss of landmarks; pneumatic otoscopy show
loss of mobility
• Breast feeding probably protective; exposure to tobacco smoke
and pacifier use thought to increase incidence
• Although caused by viruses, most cases are assumed to be bacterial
• Bacterial causes are (1) Streptococcus pneumoniae, 40-50%; (2)
Haemophilus influenzae, 20-30%; (3) Moraxella catarrhalis,
10-15%
• Differential Diagnosis
• Otitis extema
• Hemotympanum
• Cholesteatoma
• Foreign body
• Treatment
• Treatment controversial; most children with otitis media not
treated in Europe
• CDC recommendations: (I) Children> 2 not in day care and not
exposed to antibiotics in the last 3 months, give amoxicillin,
40-45mg/kg/d for 5 days; (2) children <2 in day care or with recent
antibiotic exposure, give high-dose amoxiciIlin, 80-100 mg/
kg/d for 10 days; (3) second-line therapy includes amoxiciIlinclavulanate,
cefuroxime, or intramuscular ceftriaxone
• Three or more episodes in 6 months or four episodes in a year
warrant prophylactic antihiotics; tympanostomy tuhes considered
with persistent infection
• Pearl
Nasotracheal innlbation is an overlooked cause ofotitis media.
Reference
O'Neill P: Acute otitis media. BMJ 1999;319:833. [PMID: 10496831]
+
446 Essentials of Diagnosis & Treatment
Febrile Seizures
• Essentials of Diagnosis
• Occur in 2-5% of children
• Peak age is 2 years old, boys more often affected than girls
• Last less than 15 minutes, are generalized, and occur in developmentally
normal children between 6 months and 5 years of age
• Those that are longer, focal, or multiple are complex
• Family history a risk factor
• One in three will have a recurrent seizure, 75% within a year
• Differential Diagnosis
• Meningitis
• Encephalitis
• Intracranial hemorrhage
• Intracranial tumor
• Trauma
• Treatment
• No treatment for simple febrile seizures
• Electroencephalography not recommended in the initial workup
• Lumbar puncture absolutely in children under 12 months of age,
recommended for children 12-18 months of age
• Prophylactic anticonvulsants may lower the risk of recurrence;
significant side effects limit their use
• Pearl
An excellent case can be mad.efor brain CT or MRlfoliowing any firsttime
seizure irrespective ofage.
Reference
McAbee GN et al: A practical approach to uncomplicated seizures in children.
Am Fam Physician 2000;62:1109. [PMlD: 10997534]
Chapter 18 Common Pediatric Disorders 447
Enuresis
+
• Essentials of Diagnosis
• Involuntary urination at an age where control is expected, mostly
occurring at night
• Primary enuresis occurs in chi Idren who never have had control;
secondary in children with at least 6 months of prior control
• Family history important; three-quarters of children with enuresis
have at least one parent who did
• Afflicts 20% of 5-year-olds, 10% of 7-year-olds, and 5% of
10-year-olds
Secondary enuresis often caused by psychosocial stressors
Medical problems, including UTI and diabetes mellitus, must be
excluded
• Differential Diagnosis
• Urinary tract infection
• Diabetes mellitus
• Congenital genitourinary anomalies
• Constipation
• Diuretic ingestion
• Treatment
• Therapy for causative medical problems
Support and positive reinforcement for children and families
Fluid restriction and bladder emptying prior to bedtime
Alarm systems effective but take weeks to work
• Desmopressin works quickly but does not provide long-term
control
• Imipramine not recommended due to side effects and overdose
potential
• Pearl
Hypokalemia suggests Munchausen by pro:xy due to administration of
diuretic to the child.
Reference
Gimpel GA et al: Clinical perspectives in primary nocturnal enuresis. Clin Pediatr
1998;37:23. [PMlD: 9475696]
+
448 Essentials of Diagnosis & Treatment
Urinary Tract Infection
• Essentials of Diagnosis
• Girls at higher risk than boys
• Bacterial infection of the urinary tract, defined as > 1()3 colonyfonning
units/mL by suprapubic aspiration, > 1()4 CFU/mL by
catheter, or> lOS CFU/mL clean catch
• Most common pathogens are E coli, klebsiellae, enterococci, and
Proteus mirabilis
• Urinalysis usually positive for leukocytes and bacteria
• Difficult to differentiate lower tract infections from pyelonephritis
• Differential Diagnosis
• Appendicitis
• Gastroenteritis
• Pelvic inflammatory disease (adolescents)
• Diabetes mellitus
• Urethral irritation
• Treatment
• Antibiotic choice guided by urine culture
• Treat children 1-24 months of age with cefixime or initial intravenous
cefotaxirne followed by oral cefixime
• Voiding cystourethrogram for infants and children once free of
infection to rule out vesicoureteral reflux
• Prophylactic antibiotics continued until voiding cystourethrogram
performed
• Pearl
As in adult men, urinary tract infections in children withfew exceptions
reflect an anatomic defect somewhere in the collecting system: thus,
image all.
Reference
Shaw KN et al: Urinary tract infection in the pediatric patient. Pediatr Clin North
Am 1999;46:1111. [PMID: 10629676]
Chapter 18 Common Pediatric Disorders 449
Constipation
+
• Essentials of Diagnosis
• Defined as infrequent bowel movements, usually hard in consistency
• Hard stools can lead to painful defecation and later withholding
and encopresis
• Constipation can be caused by anatomic abnormalities, neurologic
problems, or endocrine disorders; usually no cause identified
• A positive family history often elicited
• Children are capable of withholding stool voluntarily
• Rectal examination to evaluate fissures and assess rectal tone
• Abdominal radiograph may confirm the diagnosis
• Differential Diagnosis
• Hirschsprung's disease
• Hypothyroidism
• Hyperparathyroidism
• Congenital gastrointestinal malformation
• Infantile botulism
• Lead intoxication
• Treatment
• Impacted children will usually require a clean-out; although enemas
are sometimes used, severe impaction may require oral polyethylene
glycol-electrolyte solution
• Dietary changes (increased fiber and lower milk and caffeine
intake) usually beneficial
• Mineral oil titrated to one or two soft stools per day is a recommended
first-line agent
• Lactulose may be useful; Docusate sodium suspension is foultasting
and often hard for children to take
• Mainstay of therapy is behavioral; long course of toilet sitting and
positive feedhack necessary
• Families need to be told repeatedly that functional constipation
is difficult to cure and that months to years of treatment may be
necessary
• Pearl
As always in constipation, accurate definition and structural causes
come first.
Reference
Griffin GC et aJ: How to resolve stool retention in a child. Underwear soiling is
not a behavior problem. Postgrad Med 1999;105:159. [pMID: 9924501]
19
Selected Gene'lic Disorders*
Neurofibromatosis
• Essentials of Diagnosis
• Occurs either sporadically or on a familial basis with autosomal
dominant inheritance
• Two distinct forms: Type 1 (von Recklinghausen's disease), characterized
by multiple hyperpigmented macules in neurofibromas;
and type 2, characterized by eighth cranial nerve tumors
• Often present with symptoms and signs of tumor of the spinal or
cranial nerves; superficial cutaneous nerve examination reveals
palpable mobile nodules
• Associated cutaneous lesions include axillary freckling and patches
of cutaneous pigmentation (cafe au lait spots)
• Malignant degeneration of neurofibromas possible, leading to
peripheral sarcoma
• Also associated with meningioma, bone cysts, pheochromocytomas,
or scoliosis
• Differential Diagnosis
• Intracranial or intraspinal tumor due to other causes
• Albright's syndrome
• Other neurocutaneous dysplasias
• Treatment
• Genetic counseling important
Disfigurement may be corrected by plastic surgery
• Intraspinal or intracranial tumor and tumors of peripheral nerves
treated surgically if symptomatic
• Pearl
Up to six cafe au tait spots are allowed before Recklinghausen's disease
is considered.
Reference
Gabriel KR: Neurofibromatusis. CUlT Opin Pediatr 1997;9:89. lPMlD: 9088761]
* The following genetic disorders are discussed in other chapters. Chapter 4:
hemochromatosis, Wilson's disease; Chapter 5: sickle cell anemia, thalassemia,
Von Willebrand's disease; Chapter 12: Huntington's chorea; Chapter 18: cystic
fibrosis, Down's syndrome
450
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
Chapter 19 Selected Genetic Disorders 451
Acute Intermittent Porphyria
+
• Essentials of Diagnosis
• Autosomal dominant with variable expressivity
• Symptoms begin in the teens ortwenties, usually in young women;
clinically silent in most, however
• Caused by deficiency of porphobilinogen deaminase activity,
leading to increased excretion of delta-aminolevulinic acid and
porphobilinogen in the urine
• Abdominal pain, acute peripheral or central nervous system dysfunction,
recurrent psychiatric illness; cutaneous photosensitivity
absent
• Attacks precipitated by drugs (eg, barbiturates, sulfonamides,
estrogens), intercurrent infections, and alcohol
• Profound hyponatremia occasionally occurs; diagnosis confirmed
by demonstrating increasing porphobilinogen in urine during acute
attack
• Absence of fever and leukocytosis
• Differential Diagnosis
• Other causes of acute abdominal pain (appendicitis, peptic ulcer
disease, cholecystitis, diverticulitis, ruptured ectopic pregnancy,
familial Mediterranean fever)
Polyneuropathy due to other causes
Guillain-Barn~syndrome
• Heavy metal poisoning (eg, lead)
• Psychosis due to other causes
• Other causes of hyponatremia
• Treatment
• High-carbohydrate diet may diminish number of episodes in some
• Acute flares require analgesics and may require intravenous glucose
and hematin
• Pearl
In a young woman with abdominal pain and multiple surgical scars,
think acute intennittent porphyria before adding another one.
Reference
Grandchamp B: Acute intermittent porphyria. Semin Liver Dis 1998;
18:17. [PMID: 9516674]
III
+
452 Essentials of Diagnosis &Treatment
Alkaptonuria (Ochronosis)
• Essentials of Diagnosis
• Recessively inherited deficiency of the enzyme homogentisic
acid oxidase; leads to accumulation of an oxidation product in
cartilage and degenerative joint disease of the spine with purplish
joints
• A slight, darkish blue color below the skin in areas overlying cartilage
such as ears; some have more hyperpigmentation in scleras
and conjunctivas
• Aortic or mitral stenosis due to accumulation of metabolites in
heart valves; predisposition to coronary artery disease occasionally
• Back pain in spondylitis
• Diagnosed by demonstrating homogentisic acid in the urine, which
turns black spontaneously on air exposure
• Differential Diagnosis
• Ankylosing spondylitis or other spondyloarthropathies
• Osteoarthritis
• Amiodarone toxicity
• Chrysiasis
• Argyria
• Rheumatic heart disease
• Treatment
• Similar to that for other arthropathies.
• Rigid dietary restriction may be helpful
• Pearl
The only disease in medicine with black cartilage.
Reference
Femandez-Cafi6n JM et al: The molecular basis of alkaptonuria. Nat Genet
1996;14:19. [PMlD: 8782815]
Chapter 19 Selected Genetic Disorders 453
Gaucher's Disease
+
• Essentials of Diagnosis
• Autosomal recessive
• Deficiency of beta-glucocerebrosidase causes accumulation of
sphingolipid within phagocytic cells throughout body
• Infiltration primarily involves the liver, spleen, bone marrow, and
lymph nodes
• Anemia, thrombocytopenia, splenomegaly are common; erosion
of bones due to local infarction with bone pain
• Bone marrow aspirates reveal typical Gaucher cells, with eccentric
nucleus, PAS-positive inclusions; definitive diagnosis requires
demonstration of deficient glucose cerebrosidase activity
in leukocytes
• Differential Diagnosis
• Hepatomegaly, splenomegaly, lymphadenopathy due to other
causes
• Idiopathic avascular necrosis of bone, especially the hip
• Metastatic malignancy to bone
• Treatment
• Largely supportive
Splenectomy for those with bleeding problems due to platelet
sequestration
Alglucerase, given intravenously on a regular basis, probably
improves orthopedic and hematologic problems; major drawback
is exceptional cost
• Pearl
A Jewish patient with a hip fracture and splenomegaly has Gaucher's
disease until proved otherwise.
Reference
Mistry PK et al: Apractical approach to diagnosis and management of Gaucher's
disease. Baillieres Clin Haematol1997;10:817. [PMlD: 9497866]
+
454 Essentials of Diagnosis & Treatment
Homocystinuria
• Essentials of Diagnosis
• Autosomal recessive disease resulting in extreme elevations of
plasma and urinary homocystine levels, a basis for diagnosis for
this disorder
• Patients often present in second and third decades of life with evidence
of arterial or venous thromboses without underlying risk
factors for hypercoagulability
• Ectopia lentis almost always present; mental retardation common
• Repeated venous and arterial thromboses common; reduced life
expectancy from myocardial infarction, stroke, and pulmonary
embolism
• Differential Diagnosis
• Marfan's syndrome
• Other causes of mental retardation
• Other causes of hypercoagulability
• Treatment
• Treatment in infancy with pyridoxine and folate helps some
Pyridoxine nonresponders treated with dietary reduction in methionine
and supplementation of cysteine, also from infancy
• Betaine may also be useful
• Anticoagulation as appropriate for thrombosis
• Pearl
Ninety-five percent ofectopia lentis occurs in Marfan's syndrome, with
upward lens displacement; the remaining 5% have this disorder, with
downward lens dislocation.
Reference
De Franchis R et al: Clinical aspects of cystathionine beta-synthase deficiency:
how wide is the spectrum? The Italian Collaborative Study Group on Homocystinuria.
Eur J Pediatr 1998;157(SuppI2):S67. [pMlD: 9587029]
Chapter 19 Selected Genetic Disorders 455
Marfan's Syndrome
+
• Essentials of Diagnosis
• Autosomal dominant; a systemic connective tissue disease
• Characterized by abnormalities of the skeletal system, eye, and
cardiovascular system
• Spontaneous pneumothorax, ectopia lentis, and myopia are characteristic;
patients have disproportionately tall stature with long
extremities and arachnodactyly, thoracic deformity, and joint laxity
or contractures
Aortic dilation and dissection most worrisome complication;
mitral regurgitation seen occasionally
• Differential Diagnosis
• Homocystinuria
• Aortic dissection due to other causes
• Mitral or aortic regurgitation due to other causes
• Ehlers-Danlos syndrome
• Treatment
• Children should have periodic vision surveillance and annual
orthopedic consultation
• Patients of all ages require echocardiography-often annuaJlyto
monitor aortic diameter and mitral valve function; endocarditis
prophylaxis uSillllly required
• Beta-blockade may retard the rate of aortic dilation; criteria for
prophylactic replacement of the aortic root are unsettled
• Pearl
One of the few disorders in medicine immediately diagnosable by
inspection.
Reference
Pyeritz RE: The Marfan syndrome. Annu Rev Med 2000;51 :481. [PMlD:
10774478]
20
Common Disorders of the Eye
Acute Conjunctivitis
• Essentials of Diagnosis
• Acute onset of red, itchy, burning eyes with tearing, eyelid sticking,
foreign body sensation, and discharge
• Conjunctival injection and edema, mucoid or purulent discharge,
lid edema and possible preauricular lymph node enlargement
• Vision is normal or slightly decreased
• Causes include bacterial and viral (including herpetic) infections
and allergy
• Differential Diagnosis
• Acute uveitis
• Acute angle-closure glaucoma
• Corneal abrasion or infection
• Dacryocystitis
• Nasolacrimal duct obstruction
• Chronic conjunctivitis
• Scleritis in autoimmune disease
• Reactive arthritis
• Treatment
• Topical broad-spectrum ophthalmologic antibiotics
• Ophthalmology follow-up for persistent symptoms or presence
of decreased visual acuity
• Pearl
Be certain the red eye is not uveitis or episcleritis before making the
diagnosis.
Reference
Hara JH: The red eye: diagnosis and treatment. Am Fam Physician 1996;
54:2423. [PM1D: ll96 J843]
456
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
Chapter 20 Common Disorders of the Eye 457
Corneal Ulceration
+
• Essentials of Diagnosis
• Acute eye pain, photophobia, redness, tearing, discharge, and
blurred vision
• Upper eyelid edema, conjunctival injection with ciliary flush,
mucopurulent discharge, white corneal infiltrate with overlying
epithelial defect that stains with fluorescein dye, and, in some
cases, hypopyon
• Causes include trauma, contact lens wear, infection (bacterial,
herpetic, fungal, acanthamoeba)
• Differential Diagnosis
• Acute uveitis
• Acute angle-closure glaucoma
• Acute conjunctivitis
• Sterile or immunologic ulcer
• Corneal abrasion or foreign body
• Treatment
• Frequent topical broad spectrum antibiotics and daily ophthalmologic
follow-up
• Prompt ophthalmologic referral for ulcer> 2 mm in diameter
• Do not patch a corneal ulcer!
• Pearl
If the cause of corneal ulceration is not apparent, think bulbar syringomyelia.
Reference
Cohen EJ: Cornea and external disease in the new millennium. Arch Ophthalmol
2000;1 18:979. [PMTD: 10900114]
+
458 Essentials of Diagnosis & Treatment
Acute (Angle-Closure) Glaucoma
• Essentials of Diagnosis
• Less than 5% of all glaucoma
• Acute onset of eye pain and redness, photophobia, blurred vision
with colored halos around lights, headaches, nausea, or abdominal
pain
• Decreased vision, conjunctival injection with ciliary flush, steamy
cornea, mid-dilated and nonreactive pupil, and elevated intraocular
pressure by tonometry
• Preexisting narrow anterior chamber angle predisposes; older patients,
hyperopes, Asians, and Inuits more susceptible
• Precipitated by pupillary dilation caused by stress, pharmacologic
mydriasis), dark environment (eg, movie theater)
• Differential Diagnosis
• Acute conjunctivitis
• Acute uveitis
• Corneal abrasion or infection
• Other types of glaucoma
• Treatment
• Prompt ophthalmologic referral
• Pharmacotherapy includes systemic acetazolamide, topical miotic
(pilocarpine), beta-blocker (timoloJ), alpha-agonist (apraclonidine,
brimonidine), and systemic hyperosmotic agent (eg, glycerol or
mannitol).
• Laser peripheral iridotomy usually curative
• Pearl
Don't avoid a dilatedfunduscopic examination for fear ofprecipitating
acute glaucoma; you would be doing the patiell/ afavor to idell/ify this
treatable disease early.
Reference
Morgan A et al: Acute visual change. Emerg Med Clin North Am 1998;
16:825. [PMlD: 9889742]
Chapter 20 Common Disorders of the Eye 459
+
Open-Angle (Chronic) Glaucoma
• Essentials of Diagnosis
• Ninety-five percent or more of glaucoma
• Insidious onset resulting in eventual complete loss of vision;
asymptomatic early; common in blacks, elderly, and myopic
patients
• Tonometry reveals elevated intraocular pressure (> 21 mm Hg)
but highly variable
• Pathologic cupping of optic disk seen funduscopically, can be
asymmetric
• Loss of peripheral visual fields
• Differential Diagnosis
• Normal diurnal variation of intraocular pressure
• Other types of glaucoma: congenital optic nerve abnormalities;
ischemic, compressive, or toxic optic neuropathy
• Bilateral retinal disorders (chorioretinitis, retinoschisis, retinitis
pigmentosa)
• Treatment
• Beta-blocking agents (timolol)
• Miotics (pilocarpine)
• Prostaglandin analog (Iatanoprost)
• Alpha-adrenergic agents (brimonidine, apraclonidine)
• Carbonic anhydrase inhibitors (acetazolamide, dorzolamide)
• Laser trabeculoplasty, trabeculectomy, and aqueous shunt procedure
• Pearl
A patient referred by an ophthalmologist for evaluation ofdyspnea has
beta-blacker-induced asthma or congestive heart failure until proved
otherwise.
Reference
Coleman AL: Glaucoma. Lancet 1999;354: J803. [PMlD: J0577657]
+
460 Essentials of Diagnosis &Treatment
Uveitis
• Essentials of Diagnosis
• Inflammation of the uveal tract, including the iris (iritis), ciliary
body (cyclitis), and choroid (choroiditis); categorized as anterior
(iridocyclitis), posterior (chorioretinitis), or panuveitis (diffuse)
• Acute onset of eye pain and redness, photophobia, tearing, and
blurred vision (anterior uveitis); gradual visual loss with floaters,
but otherwise asymptomatic (posterior uveitis); recurrent and
bilateral
• Injected conjunctiva or sclera with flare and inflammatory cells
by slitlamp examination, white cells on corneal endothelium, and
iris nodules (anterior uveitis); white cells and opacities in the vitreous,
retinal or choroidal infiltrates, edema, and vascular sheathing
(posterior uveitis)
• Multiple causes: post trauma or surgery, lens-induced, HLAB27-
associated autoimmune diseases (eg, ankylosing spondylitis,
reactive arthritis, ulcerative colitis), Behyet's syndrome, infectious
(herpes simplex or zoster, syphilis, tuberculosis, toxoplasmosis,
toxocariasis, histoplasmosis, leprosy, Lyme disease, CMV,
candida), psoriatic arthritis, sarcoidosis, Vogt-Koyanagi-Harada
syndrome
• Differential Diagnosis
• Acute conjunctivitis
• Corneal abrasion or infection
• Retinal detachment
• Retinitis pigmentosa
• Intraocular tumor (eg, retinoblastoma, leukemia, malignant melanoma,
lymphoma)
• Retained intraocular foreign body
• Scleritis
• Treatment
• Prompt ophthalmologic referral in all cases
• Anterior disease: frequent topical steroids, periocular steroid injection,
dilation of the pupil with cycloplegic agent (eg, cyclopentolate,
scopolamine, homatropine)
Posterior disease: more commonly requires systemic steroids and
immunosuppressive agents
• Pearl
The most common ocular reflection ofsystemic disease.
Reference
Lightman S: New therapeutic options in uveitis. Eye 1997;11 (Part 2):
222. [PMID: 9349417]
Chapter 20 Common Disorders of the Eye 461
Cataract
+
• Essentials of Diagnosis
• Slowly progressive, painless visual loss or blurring, with glare
from oncoming headlights and reduced color perception
• Lens opacification grossly visible or seen by ophthalmoscopy
• Causes include aging, trauma, drugs (steroids, anticholinesterases,
anti psychotics), uveitis, radiation, tumor, retinitis pigmentosa, systemic
diseases (diabetes mellitus, hypoparathyroidism, Wilson's
disease, myotonic dystrophy, Down's syndrome, atopic dermatitis)
• Differential Diagnosis
• Generally unmistakable
• Ectopia lentis may cause some diagnostic confusion
• Treatment
• Surgical removal with intraocular lens implant for visual impairment
or occupational requirement
• Pearl
When bilateral cataracts are removed in succession, the patient is
always most grateful for the first procedure because color vision
retums.
Reference
Trudo EW et al: Cataracts. Lifting the clouds on an age-old problem. Postgrad
Med 1998; 103: 114. [PMID: 9590990]
+
462 Essentials of Diagnosis & Treatment
Retinal Vein Occlusion
(Branch, Hemiretinal, or Central)
• Essentials of Diagnosis
• Sudden, unilateral, and painless visual loss or field defect
• Local or diffuse venous dilation and tortuosity, retinal hemorrhages,
cotton-wool spots, and edema; optic disk edema and hemorrhages;
neovascularization of disk, retina, or iris by funduscopy
and slitlamp examination
• Associated underlying diseases include atherosclerosis and hypertension,
glaucoma, hypercoagulable state including factor V Leiden
or natural anticoagulant deficiency (AT-Ill, S, C), lupus anticoagulants;
hyperviscosity (polycythemia or Waldenstrom's coagulopathy),
Beh~et's syndrome, SLE
• Retrobulbar external venous compression (thyroid disease, orbital
tumor) and migraine also may be responsible
• Differential Diagnosis
• Venous stasis
• Ocular ischemic syndrome
• Diabetic retinopathy
• Papilledema
• Radiation retinopathy
• Hypertensive retinopathy
• Retinopathy of anemia
• Leukemic retinopathy
• Treatment
• Prompt ophthalmologic referral
• Laser photocoagulation for retinal ischemia and persistent macular
edema
• Surveillance and treatment of underlying diseases
• Pearl
Think ofhemoglobin SC disease in a pregnant woman with any retinal
venous occlusion.
Reference
Baumal CR et aI: Treatment of central retinal vein occlusion. Ophthalmic Surg
Lasers 1997;28:590. [PMID: 9243663]
Chapter 20 Common Disorders of the Eye 463
+
Retinal Artery Occlusion (Branch or Central)
• Essentials of Diagnosis
• Sudden unilateral and painless loss of vision or visual field defect
• Focal wedge-shaped area of retinal whitening or edema within
the distribution of a branch arteriole or diffuse retinal whitening
with a cherry-red spot at the fovea; arteriolar constriction with
segmentation of blood column; visible emboli
• Macular vision unaffected because of external carotid collateral
• Associated underlying diseases include carotid plaque or cardiacsource
emboli; vasculitis; less common than vein occlusion in
hypercoagulable states
• Differential Diagnosis
• Ophthalmic artery occlusion
• Inherited metabolic or lysosomal storage disease
• Ocular migraine
• Treatment
• Medical emergency calling for immediate ophthalmologic referral
• Digital ocular massage, systemic acetazolamide or topical betablocker
to lower intraocular pressure, anterior chamber paracentesis,
and carbogen treatment
• Consider thrombolysis
• Pearl
The retina is part o/the central nervous system, and this disorder is thus
treated as one does a stroke.
Reference
Kosmorsky GS: Sudden painless visual loss: optic nerve and circulatory disturbances.
Clin Gerialr Med 199915: I. [PMlD: 9855655]
+
464 Essentials of Diagnosis & Treatment
Retinal Detachment
• Essentials of Diagnosis
• Acute onset of photopsias (flashes of light), tloaters ("shade"
or "cobwebs"), a curtain or shadow across the visual field, and
peripheral or central visual loss
• Elevation of the retina with a flap tear or break in the retina, vitreous
pigmented cells or hemorrhage seen by ophthalmoscopy
• Risk factors include lattice vitreoretinal degeneration, posterior
vitreous separation (especially with vitreous hemorrhage), high
myopia, trauma, and previous ocular surgery (especially with vitreous
loss)
• Differential Diagnosis
• Retinoschisis
• Choroidal detachment
• Posterior vitreous separation
• Treatment
• Immediate ophthalmologic referral
• Bed rest with bilateral patching
• Closure of retinal tear by pneumatic retinopexy, scleral buckling
with cryopexy, pars plana vitrectomy with drainage, endoJaser,
cryopexy, membrane peel, gas or silicone oil injection
• Repair of small tears by laser photocoagulation or cryopexy
• Pearl
Retinal detachment is the most common nonorthopedic injury sustained
playing tennis doubles.
Reference
Elfervig LS et aI: Retinal detachment. Insight 1998;23:66. [PMlD: 9866533]
Chapter 20 Common Disorders of the Eye 465
Diabetic Retinopathy
+
• Essentials of Diagnosis
Asymptomatic; may have decreased or fluctuating vision or
floaters
• Nonproliferative: dot and blot hemorrhages, microaneurysms,
hard exudates, cotton-wool spots, venous beading, and intraretinal
microvascular abnormalities
Proliferative: neovascularization of optic disk, retina, or iris; preretinal
or vitreous hemorrhages and tractional retinal detachment
• Differential Diagnosis
• Hypertensive retinopathy
• Radiation retinopathy
• Central or branch retinal vein occlusion
• Ocular ischemic syndrome
• Sickle cell retinopathy
• Retinopathy of severe anemia
• Embolization from intravenous drug abuse (taIc retinopathy)
• Collagen-vascular disease
• Sarcoidosis
Eales' disease
• Treatment
• Ophthalmologic referral and regular follow-up in all diabetics
Laser photocoagulation for macular edema and proliferative
disease
• Pars plana vitrectomy for nonclearing dense vitreous hemorrhage
and tractional retinal detachment involving or threatening the
macula
• Pearl
Seventy-five percent ofdiabetics develop significant retinopathy within
15 years after diagnosis; nearly one-fourth never develop retinopathy.
Reference
Ferris FL 3rd et al: Treatment of diabetic retinopathy. N Engl J Med 1999;
341 :667. [PM1D: 10460819]
+
466 Essentials of Diagnosis & Treatment
Age-Related Macular Degeneration
• Essentials of Diagnosis
• Nonexudative (dry) form: central or paracentral blind spot and
gradual loss of central vision; may be asymptomatic
• Small and hard or large and soft drusen, geographic atrophy of
the retinal pigment epithelium, and pigment clumping
• Exudative (wet) form: distortion of straight lines or edges, central
or paracentral blind spot, and rapid loss of central vision
• Gray-green choroidal neovascular membrane, lipid exudates, subretinal
hemorrhage or Auid, pigment epithelial detachment, and
fibrovascular disciform scars
• Risk factors include increasing age, positive family history, cigarette
smoking, hyperopia, light iris color, hypertension, and
cardiovascular disease
• Differential Diagnosis
• Prominent drusen
• Choroidal neovascularization from other causes (eg, ocular histoplasmosis,
angioid streaks, myopic degeneration, traumatic
choroidal rupture, optic disk drusen, choroidal tumors, laser
scars, and inflammatory chorioretinallesions)
• Treatment
• Prompt ophthalmologic referral
• Laser photocoagulation, photodynamic therapy, submacular surgery,
and macular translocation for choroidal neovascularization
• Pearl
Age-related macular degeneration is the third leading cause of blindness
in America (after glaucoma and diabetic retinopathy).
Reference
Fine SL et al: Age-related macular degeneration. N Engl J Med 2000;342:483.
[PMJD: 10675430]
Chapter 20 Common Disorders of the Eye 467
Hypertensive Retinopathy
+
• Essentials of Diagnosis
• Usually asymptomatic; may have decreased vision
• Generalized or localized retinal arteriolar narrowing, almost always
bilateral
• Arteriovenous crossing changes (A-Y nicking), retinal arteriolar
sclerosis (copper or silver wiring), cotton-wool spots, hard exudates,
flame-shaped hemorrhages, retinal edema, arterial macroaneurysms,
chorioretinal atrophy
• Optic disk edema in malignant hypertension
• Differential Diagnosis
• Diabetic retinopathy
• Radiation retinopathy
• Central or branch retinal vein occlusion
• Sickle cell retinopathy
• Retinopathy of severe anemia
• Embolization from intravenous drug abuse (talc retinopathy)
• Autoimmune disease
• Sarcoidosis
• Eales' disease
• Treatment
• Treat the hypertension
• Ophthalmologic referral
• Pearl
The only pathognomonic funduscopic change of hypertension is focal
arteriolar narrowing-and that is typically seen in hypertensive crisis.
Reference
Schubert HD: Ocular manifestations of systemic hypertension. Curr Opin OphthalmoJ
1998;9:69. [PMTD: 10387339J
+
468 Essentials of Diagnosis & Treatment
Pingueculum & Pterygium
• Essentials of Diagnosis
• Pingueculum: yellow-white fiat or slightly raised conjunctival
lesion in the interpalpebral fissure adjacent to the limbus but not
involving the cornea
• Pterygium: wing-shaped fold of fibrovascular tissue arising from
the interpalpebral conjunctiva and extending onto the cornea
Irritation, redness, decreased vision; may be asymptomatic
• Both lesions can be highly vascularized and injected; their growth
associated with sunlight and chronic irritation
• Differential Diagnosis
• Conjunctival intraepithelial neoplasia
• Dermoid
• Pannus
• Treatment
• Protect the eyes from sun, dust, and wind with sunglasses or
goggles
• Reduce ocular irritation with artificial tears or mild topical steroid
• Surgical removal with extreme irritation not relieved with above
treatment, extension of pterygium to the pupillary margin, or
irregular astigmatism
• Pearl
Xanthomas always, xanthelasma sometimes, and pterygium and pingueculum
are never associated with hyperlipidemia-except coincidentally.
Reference
Hoffman RS et al: Current options in pterygium management. Int Ophthalmol
Clin 1999;39: 15. [PMTD: 10083903]
Chapter 20 Common Disorders of the Eye 469
Hordeolum &Chalazion
+
• Essentials of Diagnosis
• Eyelid lump, swelling, pain, and redness
• Visible or palpable, well-defined subcutaneous nodule within the
eyelid; eyelid edema, erythema, and tenderness with or without
preauricular node
• Hordeolum: acute obstruction and infection of eyelid gland (meibomian
gland-internal hordeolum, gland of Zeis or Mollexternal
hordeolum), associated with Staphylococcus aureus
• Chalazion: chronic obstruction and inAammation of meibomian
gland with leakage of sebum into surrounding tissue with resultant
lipogranuloma; rosacea may be associated
• Differential Diagnosis
• Preseptal cellulitis
• Sebaceous cell carcinoma
• Pyogenic granuloma
• Treatment:
• Warm compresses for 15-20 minutes at least 4 times daily
• Topical antibiotic ointment twice daily
• Incision and curettage for persistent chalazion (> 6-8weeks)
• Intralesional steroid injection for chalazion near the nasolacrimal
drainage system
• Pearl
Hord.eolwn-this kernel-type abscess gets its nameji-om the Latin word.
for barleycorn.
Reference
Lederman C et al: Hordeola and chalazia. Pediatr Rev 1999;20:283. [PMID:
10429150]
+
470 Essentials of Diagnosis & Treatment
Blepharitis & Meibomianitis
• Essentials of Diagnosis
• Chronic itching, burning, mild pain, foreign body sensation, tearing,
and crusting around the eyes on awakening
• Crusty, red, thickened eyelids with prominent blood vessels or
inspissated oil glands in the eyelid margins, conjunctival injection,
mild mucoid discharge, and acne rosacea
• Differential Diagnosis
• Sebaceous gland carcinoma
• Treatment
• Warm compresses for 15 minutes, followed by scrubbing the eyelid
margins with baby shampoo at least twice daily
• Artificial tears for irritation
• Topical antibiotic ointment at bedtime
• Recurrent or persistent meibomitis treated with doxycycline for
6-8 weeks, followed by slow taper; in women, negative pregnancy
test before and contraception during treatment essential
• Pearl
No precaution is too prudent when contemplating treatment of young
women with tetracycline.
Reference
Caner SR: Eyelid disorders: diagnosis and management. Am Fam Physician
1998;57:2695. [PMlD: 9636333]
2
Common Disorders 01 the
Ear, Nose, .. Throat
Chronic Serous Otitis Media
• Essentials of Diagnosis
• Owing to obstruction of the auditory tube, resulting in transudation
of fluid
• Allergic and immune factors probably contribute
• More common in children but can occur in adults following an
upper respiratory tract infection, barotrauma, air travel, or auditory
tube obstruction by tumor
• Painless hearing loss with feeling of fullness or voice reverberation
in affected ear
• Dull, immobile tympanic membrane with loss of landmarks and
bubbles seen behind tympanic membrane; intact light reflex
• Fifteen- to 20-decibel conductive hearing loss by audiometry and
Weber tuning fork examination lateralizing to affected ear
• Differential Diagnosis
• Acute otitis media
• Nasopharyngeal tumor (as causative agent)
• Treatment
• Oral decongestants, antihistamines, and antibiotics
• Tympanotomy tubes for refractory cases with audiology and otolaryngology
referral
• Pearl
Unilateral otitis media, especially in a patient of Asian ethnicity, is
nasopharyngeal carcinoma until proved otherwise-mirror examination
ofthe nasopharynx is obligatory.
Reference
Osma U et al: The complications of chronic otitis media: report of 93 cases.
J Laryngol 01012000;114:97. [PMlD: 10748823]
471
Copyright 2002 The McGraw-Hili Companies, Inc. Click Here for Terms of Use.
+
472 Essentials of Diagnosis &Treatment
Acute Otitis Media
• Essentials of Diagnosis
• Ear pain, with sensation offullness in ear and hearing loss; fever
and chi Us; onset often following upper respiratory syndrome
• Dullness and hyperemia of eardrum with loss of landmarks and
light reflex
• Most common organisms in both children and adults include
Streptococcus pneurrwniae, Haemophilus influenzae, Moraxella
catarrhalis, and group A streptococcus
• Complications include mastoiditis, skull base osteomyelitis, sigmoid
sinus thromboses, meningitis, brain abscess
• Differential Diagnosis
• Bullous myringitis (associated with mycoplasmal infection)
• Acute external otitis
• Otalgia referred from other sources (especially pharynx)
• Serous otitis
• Treatment
Antibiotics versus supportive care controversial; oral decongestants
• Tympanostomy tubes for refractory cases, with audiology and
otolaryngology referral
• Recurrent acute otitis media may be prevented with long-term
antibiotic prophylaxis
• Pearl
With unexplained fever in a ventilated patient, look in the ears: otitis
media can result from auditory tube obstruction by the nasotracheal
tube.
Reference
Damoiseaux RA et al: Primary care based randomized, double blind trial of
amoxiciUin versus placebo for acute otitis media in children aged under 2
years. BMJ 2000;320:350. [PMlD: 10657332]
+
Chapter 21 Common Disorders of the Ear, Nose, & Throat 473
Endolymphatic Hydrops (Meniere's Syndrome)
• Essentials of Diagnosis
• Etiology is unknown
• Due to distention of the endolymphatic compartment of the
inner ear
• The four tenets: episodic vertigo and nausea (lasting 1-8 hours),
aural pressure, continuous tinnitus, and fluctuating hearing loss
• Sensorineural hearing loss by audiometry starting in the low frequencies
• Differential Diagnosis
• Benign positioning vertigo
• Posterior fossa tumor
• Vestibular neuronitis
• Vertebrobasilar insufficiency
• Psychiatric disorder
• Multiple sclerosis
• Syphilis
• Treatment
• Low-salt diet and diuretic
• Antihistamines, diazepam, and antiemetics may be given parenterally
for acute attacks
• Aminoglycoside ablation of unilateral vestibular function via middle
ear infusion
• Surgical treatment in refractory cases: decompression of endolymphatic
sac, vestibular nerve section, or labyrinthectomy if
profound hearing loss present
• Pearl
One ofthe few unilateral diseases ofpaired organs.
Reference
Saeed SR: Fortnightly review. Diagnosis and treatment of Meniere's disease.
BMJ 1998;3t6:368. [PMID: 9487176]
+
474 Essentials of Diagnosis &Treatment
Benign Positioning Vertigo
• Essentials of Diagnosis
• Acute onset of vertigo, nausea, tinnitus
• Provoked by changes in head positioning rather than by maintenance
of a particular posture
• Nystagmus with positive Barany test (delayed onset of symptoms
by movement of head with habituation and fatigue of symptoms)
• Differential Diagnosis
• Endolymphatic hydrops
• Vestibular neuronitis
• Posterior fossa tumor
• Vertebrobasi lar insufficiency
• Migraines
• Treatment
• Intravenous diazepam, antihistamines, and antiemetics for acute
attack
• Reassurance with otolaryngologic referral for persistent symptoms
or other neurologic abnormalities
• Single-session physical therapy protocols may be useful in some
patients
• Pearl
Learn this well-it's the most common cause a/vertigo encountered in
primary care settings.
Reference
Furman JM et al: Benign paroxysmal positional vertigo. N Engl J Med 1999;
341: 1590. [pMTD: 10564690]
+
Chapter 21 Common Disorders of the Ear, Nose, & Throat 475
Acute Sinusitis
• Essentials of Diagnosis
• Nasal congestion, purulent discharge, facial pain, and headache;
teeth may hurt or feel abnormal in maxillary sinusitis; history of
allergic rhinitis, acute upper respiratory infection, or dental infection
often present
• Fever, toxicity; tenderness, erythema, and swelling over affected
sinus; discolored nasal discharge and poor response to decongestants
alone
• Clouding of sinuses on imaging or by transillumination
• Coronal CT scans have become the diagnostic study of choice
Pain not prominent in chronic sinusitis-a poorly defined entity
• Typical pathogens include Streptococcus pneurrwniae, other streptococci,
Haemophilus influenzae, Staphylococcus aureus, Moraxelfa
catarrhalis; aspergillus in mv patients
• Complications: orbital cellulitis or abscess, meningitis, brain
abscess
• Differential Diagnosis
• Viral or allergic rhinitis
• Dental abscess
• Dacryocystitis
• Carcinoma of sinus
Headache due to other causes, especially cluster headache
• Treatment
• Oral and nasal decongestants, broad-spectrum antibiotics, nasal
saline
• Functional endoscopic sinus surgery or external sinus procedures
for medically resistant sinusitis, nasal polyposis, sinusitis complications
• Pearl
Sphenoid sinusitis is the only cause in medicine ofa nasal ridge headache
radiating to the top ofthe skull.
Reference
Poole MD: A focus on acute sinusitis in adults: changes in disease management.
Am J Med 1999;106:385. [PMTD: 10348062]
+
476 Essentials of Diagnosis &Treatment
Allergic Rhinitis (Hay Fever)
• Essentials of Diagnosis
• Seasonal or perennial occurrence of watery nasal discharge, sneezing,
itching of eyes and nose
• Pale, boggy mucous membranes with conjunctival injection
• Eosinophilia of nasal secretions and occasionally of blood
• Positive skin tests often present but oflittle value in most instances
• Differential Diagnosis
• Upper respiratory viral infections
• Treatment
• Desensitization occasionally beneficial, especially in younger
patients
• Oral antihistamines; oral or inhaled decongestants
• Short-course systemic steroids for severe cases
• Nasal corticosteroids and nasal cromolyn sodium often effective
if used correctly
• Pearl
A Wright's flambe ofsecretions is the best way to demonstrate eosinophils:
stain the smear, ignite it. decolorize it, and the cells will be seen
readily at low power.
Reference
Corren J: Allergic rhinitis: treating the adult. J Allergy Clin Immunol 2000;
105(6 Part 2):S610. [PMlD: 10856166]
+
Chapter 21 Common Disorders of the Ear, Nose, & Throat 477
Epiglottitis
• Essentials of Diagnosis
• Sudden onset of stridor, odynophagia, dysphagia, and drooling
• Muffled voice, toxic-appearing and febrile patient
• Cherry-red, swollen epiglottis on indirect laryngoscopy; pharynx
typically normal or slightly injected
• Should be suspected when odynophagia is out of proportion to
oropharyngeal findings
• Differential Diagnosis
• Viral croup
• Foreign body in larynx
• Retropharyngeal abscess
• Treatment
• Humidified oxygen with no manipulation of oropharynx or
epiglottis
• Airway observation in monitored setting, intubation with tracheotomy
stand-by
• Children usually need intubation-adults need close airway observation
• Parenteral antibiotics active against Haemophilus influenzae and
short burst of systemic corticosteroids
• Pearl
The patient with a severe sore throat and unimpressive pharyngeal
examination by tongue blade has epiglottitis until proved otherwise.
Reference
Park KW et al: Airway management for adult patients with acute epiglottitis: a
12-year experience at an academic medical center (1984-1995). Anesthesiology
1998;88:254. [PMID: 9447879]
+
478 Essentials of Diagnosis &Treatment
External Otitis
• Essentials of Diagnosis
• Presents with otalgia, often accompanied by pruritus and purulent
discharge
• Usually caused by gram-negative rods or fungi
• Often a history of water exposure or trauma to the ear canal
• Movement of the auricle elicits pain; erythema and edema of the
ear canal with a purulent exudate on examination
• When visualized, tympanic membrane is red but moves normally
with pneumatic otoscopy
• Differential Diagnosis
• Malignant otitis externa (external otitis in an immunocompromised
or diabetic patient with osteomyelitis of the temporal bone);
pseudomonas causative in diabetes
• Treatment
• Prevent additional moisture and mechanical injury to the ear canal
• Otic drops containing a mixture of an aminoglycoside or quinolones
and a corticosteroid
Purulent debris filling the canal should be removed; occasionally,
a wick is needed to facilitate entry of the otic drops
Analgesics
• Pearl
A painful red ear in a diabetic is assumed to be malignant otitis extema
until proved otherwise.
Reference
Ostrowski VB et aI: Pathologic conditions of the external ear and auditory canal.
Postgrad Med 1996;100:223. [PMID: 8795656]
+
Chapter 21 Common Disorders of the Ear, Nose, & Throat 479
Viral Rhinitis (Common Cold)
• Essentials of Diagnosis
• Headache, nasal congestion, watery rhinorrhea, sneezing, scratchy
throat, and malaise
• Due to a variety of viruses, including rhinovirus and adenovirus
• Examination of the nares reveals erythematous mucosa and
watery discharge
• Differential Diagnosis
• Acute sinusitis
• Allergic rhinitis
• Bacterial pharyngitis
• Treatment
• Supportive treatment only
• Phenylephrine nasal sprays (should not be used for more than
5-7 days) and decongestants may be useful
• Secondary bacterial infection suggested by a change of rhinorrhea
from clear to yellow or green; cultures are useful to guide
antimicrobial therapy
• Pearl
To date, no cure has been discovered/or the common cold; physicians
should not anticipate one.
Reference
Massad SB: Treaunent of the common cold. BMJ 1998;317:33. [PMlD:
9651268]
+
480 Essentials of Diagnosis &Treatment
Acute Sialadenitis
(Parotitis, Submandibular Gland Adenitis)
• Essentials of Diagnosis
• Inflammation of parotid or submandibular gland due to salivary
stasis and infection
• Facial swelling and pain overlying the parotid or submandibular
gland
• Often seen in severe dehydration
• Examination shows erythema and edema over affected gland and
pus from affected duct
• Leukocytosis
• Complications: parotid or submandibular space abscess
• Differential Diagnosis
• Salivary gland tumor
• Facial cellulitis or dental abscess
• Sjogren's syndrome
• Mumps
• Lymphoepithelial cysts in immunocompromised patients
• Treatment
• Antibiotics with gram-positive coverage
• Warm compresses
• Hydration
• Oral rinses
• Pearl
Lookfor this in marathon runners after the race on hot days; hyperamy/
asemia clinches the diagnosis.
Reference
Silvers AR et al: Salivary glands. Radiol Clin North Am 1998;36:941. [PMID:
9747195]
22
Poisoning
Acetaminophen (Tylenol; Many Others)
• Essentials of Diagnosis
• Nausea and vomiting after ingestion; may be no signs of toxicity
until 24-48 hours after ingestion
• Serum acetaminophen levels measured 4 hours after ingestion or
at initial evaluation if longer than 4 hours since ingestion; level
should be obtained in all drug overdoses
• Hepatic and renal injury not apparent until after 36-72 hours
• Striking elevations in aminotransferases; in some cases, fulminant
hepatic necrosis
• Patients may not realize that combination analgesics (eg, Tylenol
No.3, Vicodin, Darvocet) contain acetaminophen
• Differential Diagnosis
• Other hepatotoxin ingestion (eg, Amanita mushrooms, carbon
tetrachloride)
• Alcoholic liver disease
• Viral hepatitis
• Overdose of other drug
• Treatment
• Activated charcoal
• Gastric lavage if less than I hour since ingestion
Acetylcysteine (140 mg/kg orally, followed by 70 mg/kg every
4 hours) if serum level is higher than toxic line on standard nomogram
• Pearl
A serum acetaminophen should be obtained in all overdoses: once
hepatotoxicity ensues, therapy is valueless, and the depressed suicidal
patient tends to ingest multiple drugs.
Reference
Salgia AD el al: When acetaminuphen use becomes tuxic. Treating acute accidental
and intentional overdose. Postgrad Med 1999;105:81. [PMID:
102123088]
481
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
+
482 Essentials of Diagnosis & Treatment
Amphetamines, Ecstasy, Cocaine
• Essentials of Diagnosis
• Sympathomimetic clinical scenario: anxiety, tremulousness, agitation,
tachycardia, hypertension, diaphoresis, dilated pupils, muscular
hyperactivity, hyperthermia
• With cocaine in particular, stroke and myocardial infarction from
vasospasm
• Psychosis, seizures
• Metabolic acidosis may occur
• Urine toxicology screen
• Ecstasy (MDMA) associated with serotonin syndrome (see antidepressants)
and malignant hyperthermia
• Differential Diagnosis
• Anticholinergic poisoning
• Functional psychosis
• Exertional heat stroke
• Other stimulant overdose (eg, ephedrine, phenylpropanolamine)
• Treatment
• Activated charcoal for oral ingestions
• Gastric lavage if less than j hour since ingestion
• Chemistry panel and creatine kinase for metabolic acidosis, renal
failure, and rhabdomyolysis
• For agitation or psychosis: sedation with benzodiazepines
(Iorazepam or diazepam)
• For hyperthermia: remove clothing, cool mist spray, cooling
blanket
• For hypertension: phentolamine, nifedipine, nitroprusside, or
labetalol (not propranolol because it may generate unopposed
alpha-adrenergic effects and worsen hypertension)
• For tachyarrhythmias or tachycardia, use esmolol-the short
half-life allows rapid dissipation of effect if necessary
• Pearl
Chest pain in a middle-class patient with running shoes and casual
clothing equals cocaine-induced coronary vasospasm.
Reference
Ghuran A et aI: Recreational drug misuse: issues for the cardiologist. Heart
2000;83;:627. [PMJD: 10814617]
Chapter 22 Poisoning 483
+
Antidepressants: Atypical Agents (Serotonin Syndrome)
• Essentials of Diagnosis
• Trazodone, bupropion, venlafaxine, and the SSRls (f1uoxetine, sertraline,
paroxetine, f1uvoxamine, and citalopram); well-tolerated in
pure overdoses, high toxic-to-therapeutic ratios
• History of ingestion paramount
• Serotonin syndrome: changes in cognition or behavior (confusion,
agitation, coma), autonomic dysfunction (hyperthermia, diaphoresis,
tachycardia, hypertension), and neuromuscular activity
(myoclonus, hyperreflexia, muscle rigidity, tremor, ataxia)
• Differential Diagnosis
• Alcohol withdrawal
• Heat stroke
• Hypoglycemia
• Neuroleptic malignant syndrome
• Treatment
• Activated charcoal
• Gastric lavage if less than I hour since large ingestion or if a
mixed drug ingestion
• Cardiac monitoring and ECG based on specific agent
• Benzodiazepines initially; bupropion, venlafaxine, and SSRIs
associated with seizures
• Serotonin syndrome typically self-limited; stop all offending
agents
• Cyproheptadine (an antiserotonergic agent) in serotonin syndrome
(4-8 mg orally, repeated once in 2 hours if no response)
• Pearl
Serotonin syndrome is more frequently due to the combination of an
SSR/ and another serotonergic agent: rave participants increase the
risk by taking an SSRI ("preloading") followed by ecstasy.
Reference
Carbone JR: The neuroleptic malignant and serotonin syndromes. Emerg Med
Clin Nonh Am 2000;18:317. [PMID: 10767887]
11II
+
484 Essentials of Diagnosis &Treatment
Antidepressants: Tricyclics
• Essentials of Diagnosis
• Tricyclic antidepressants include amitriptyline, desipramine, doxepin,
imipramine, and nortriptyline
• Peripheral anti muscarinic effects: tachycardia, dry mouth, dry skin,
muscle twitching, decreased bowel activity, dilated pupils; may be
offset by TCA-mediated alpha-adrenergic receptor inhibition
• Central anti muscarinic effects: agitation, delirium, confusion,
hallucinations, slurred speech, ataxia, sedation, coma
• Cardiotoxic efFects From voltage-dependent sodium channel inhibition:
PR and QRS interval widening, right axis deviation of
terminal 40 ms (terminal R in aVR, S in lead I), depressed contractility,
heart block, hypotension, ectopy; QT prolongation from
potassium channel antagonism
• Generalized seizures from GABA-A receptor antagonism
• Toxicity can occur at therapeutic doses in combination with other
drugs (antihistamines, anti psychotics)
• Differential Diagnosis
• Other drug ingestions: carbamazepine, antihistamines, class Ia
and Ie antiarrhythrnics, propranolol, lithium
• Cocaine toxicity
• Hyperkalemia
• Treatment
• Activated charcoal
• Gastric lavage if less than I hour since ingestion
Urine screen for other ingestions; qualitative TCA screen
Electrocardiographic and cardiac monitoring
• Sodium bicarbonate for QRS > 100 ms, refractory hypotension,
or ventricular dysrhythmia (1-2 meq/kg boluses to goal serum
pH 7.50-7.55, then infuse DsW with three ampules sodium bicarhonate
at 2-1 mL/kg/h)
• Benzodiazepines for seizures
• Pearl
TeAs are responsible for rrwre drug-related deaths than any other prescribed
medications-and are the most difficult to treat.
Reference
Ujhelyi MR: Assessment of tricyclic antidepressant toxicity: looking for a needle
in a pharmacologic haystack. Crit Care Med 1997;25: 1634. [PMID:
9377874] -
Chapter 22 Poisoning 485
Arsenic
+
• Essentials of Diagnosis
• Leading cause of acute metal poisoning; second leading cause of
chronic metal toxicity
• Symptoms appear within 1 hour after ingestion but may be delayed
as long as 12 hours
• Severe abdominal pain, vomiting, watery diarrhea, metallic taste,
skeletal muscle cramps, dehydration, delirium, seizures, and shock
in acute overdose
• With chronic ingestion, hypotension, gastroenteritis, peripheral
neuropathy (stocking-glove distribution), nonspecific malaise,
skin rash, anemia, and leukopenia
• Abdominal x-ray may demonstrate metallic ingestion
• Differential may reveal relative eosinophilia; smear may show
basophilic stippling of red cells
• ECG shows prolonged QT interval, especially in chronic toxicity
• Differential Diagnosis
• Septic shock
• Other heavy metal toxicities, including thallium and mercury
Other peripheral neuropathies, including Guillain-Barre syndrome
Addison's disease
• Hypo- and hyperthyroidism
• Treatment
• Gastric lavage for acute large ingestion
• Activated charcoal may adsorb other ingested toxins
• Whole-bowel irrigation if radiopaque material visible on abdominal
x-ray
• Chelation therapy of dimercaprol in acute symptomatic ingestions
• Oral succimer (DMSA) preferred and less toxic agent for stable
patients with suspected chronic toxicity
• Twenty-four-hour urinary arsenic levels
• Pearl
A gaseous form (arsine) produces acute hemolytic anemia; treatment
differs from that ofpoisoning with inorganic compounds.
Reference
Graeme KA et al: Heavy metal toxicity, Part [: arsenic and mercury.
J Emerg Med 1998;16:45. [PMID: 9472760]
+
486 Essentials of Diagnosis & Treatment
Beta-Blockers
• Essentials of Diagnosis
• Hypotension, bradycardia, atrioventricular block, cardiogenic
shock
Altered mental status, psychosis, seizures, and coma may occur
with propranolol, metoprolol, and other lipophilic agents
• Onset of symptoms typically 1-3 hours, may be from 15 minutes
to 10 hours
• Bronchospasm or hypoglycemia infrequent
• Differential Diagnosis
• Calcium antagonist overdose
• Digitalis or other cardiac glycoside ingestion
• Tricyclic antidepressant toxicity
• Treatment
• Gastric lavage if less than I hour since ingestion
• Activated charcoal
• Electrocardiographic and cardiac monitoring
• For bradycardia and hypotension, if refractory to normal saline
bolus, then glucagon bolus (0.05-0.15 mg/kg) followed by intravenous
infusion (0.075-0.15 mg/kg/h)
• If glucagon insufficient or unavailable, then dopamine or norepinephrine
infusion
• Isoproterenol, magnesium, correction of hypokalemia, sodium
bicarbonate, overdrive pacing, or aortic balloon pump
• Supportive therapy for coma or seizures
• Pearl
Be wary ofunopposed alpha-agonism in beta-blocker ingestion, especially
in hypertensives who may have pheochromocytoma.
Reference
Lip GY et aI: Poisoning with anti-hypertensive drugs: beta-adrenoceptor blocker
drugs. J Hum Hypertens 1995;9:213. [PMID: 7595901]
III
Chapter 22 Poisoning 487
+
Calcium Antagonists (Calcium Channel Blockers)
• Essentials of Diagnosis
• Bradycardia, hypotension, atrioventricular block
• Cardiac arrest or cardiogenic shock
• Decreased cerebral perfusion leads to confusion or agitation,
dizziness, lethargy, seizures
• Differential Diagnosis
• Beta-blocker toxicity
• Tricyclic antidepressant toxicity
• Digitalis toxicity
• Hypotensive, bradycardiac shock typically distinct from hyperdynamic
shock of hypovolemia or sepsis
• Treatment
• Gastric lavage if less than 1 hour since ingestion
• Activated charcoal
• Whole bowel irrigation and repeated charcoal for large overdose
of sustained-release preparations
• Electrocardiographic and cardiac monitoring
• Monitor electrolytes for acidosis, hyperkalemia, hypocalcemia
Supportive therapy for coma, hypotension, and seizures
• To reverse cardiotoxic effects: fluid boluses, then calcium chloride
boluses to obtain ionized calcium of 2-3 meq/L; if ineffective,
then glucagon (0.1 mg/kg intravenous bolus, then 0.1 mg/kg/h
infusion); if refractory, then dopamine or norepinephrine
• To improve rate and contractility, there may be roles for amrinone,
atropine, high-dose insulin with dextTose, or aminopyridine;
rescue methods include slow (50 beats/min) cardiac pacing,
aortic balloon pump, hemoperfusion, and bypass
• Pearl
Verapamil is the most potent negative inotrope ofthe calcium blockers;
beware ofits use in cardiomyopathic patients with arrhythmias.
Reference
Proano L et al: Calcium channel blocker overdose. Am J Emerg Med 1995;
13:444. [pMlD: 7605536]
11II
+
488 Essentials of Diagnosis & Treatment
Carbon Monoxide
• Essentials of Diagnosis
• May result from exposure to automobile exhaust, smoke inhalation,
or improperly vented gas heater
• Symptoms nonspecific and flu-like: fatigue, headache, dizziness,
abdominal pain, nausea, confusion
• With more severe intoxication, cherry-red skin, lethargy, seizures,
coma
• Secondary injury from ischemia: myocardial infarction, rhabdomyolysis,
noncardiogenic pulmonary edema, renal failure
• Survivors of severe poisoning may have permanent neurologic
deficits
• Elevated anerial or venous carboxyhemoglobin level; routine
arterial blood gases, and pulse oximetry may indicate falsely normal
oxygen saturation levels
• Differential Diagnosis
• Cyanide poisoning
• Depressant drug ingestion
• Myocardial ischemia
• In chronic intoxication, headache of other cause
• Treatment
• Specific treatment depends on clinical symptoms
• Remove from exposure
• Maintain airway and assist ventilation; intubation may be necessary
100% oxygen by nonrebreathing face mask
• Hyperbaric oxygen if response limited or in the setting of loss of
consciousness, myocardial ischemia, or a pregnant patient
• Pearl
Elevated hematocrit and headache in an auto repairman or traffic
policeman suggest the diagnosis.
Reference
Piantadosi CA: Diagnosis and treatment of carbon monoxide poisoning. Respir
Care Clin N Am 1999;4: 183. [PMID: 10333448]
III
Chapter 22 Poisoning 489
+
Cardiac Glycosides (Digitalis)
• Essentials of Diagnosis
• Accidental ingestion, single large ingestion, or chronic use
• Age, coexisting disease, electrolyte disturbance (hypokalemia,
hypomagnesemia, hypercalcemia), hypoxia, and other cardiac
medications (including diuretics) increase potential for digitalis
toxicity
• Acute overdose: nausea, vomiting, severe hyperkalemia, visual disturbances,
syncope, confusion, delirium, bradycardia, supraventricular
or ventricular dysrhythmias, atrioventricular block
• Chronic toxicity: nausea, vomiting, ventricular arrhythmias
Elevated serum digoxin level in acute overdose; level may be
normal with chronic toxicity
• Differential Diagnosis
• Cardiotoxic plant or animal ingestion: oleander, foxglove, lily of
the valley, rhododendron, toad venom
• Beta-blocker toxicity
• Calcium blocker toxicity
• Tricyclic antidepressant ingestion
• Clonidine overdose
Organophosphate insecticide poisoning
• Treatment
• Activated charcoal
Gastric lavage if less than I hour since ingestion
Electrocardiographic and cardiac monitoring
Maintain adequate airway and assist ventilation as necessary
• Correct hypomagnesemia, hypoxia, hypoglycemia, hyperkalemia
or hypokalemia; calcium is contraindicated, as it may generate
ventricular arrhythmias
Lidocaine, phenytoin, magnesium for ventricular arrhythmias;
avoid quinidine, procainamide, and hretylium
Atropine, pacemaker for bradycardia or atrioventricular block
• Ventricular arrhythmias, unresponsive bradyarrhythmias, and
hyperkalemia with digoxin toxicity are indications for using
digoxin-specific antibodies (Digibind); base dosing on estimated
ingestion
• Pearl
Digitalis may cause or treat any arrhythmia: if they're not on it, start
it; if they're on it, stop it.
Reference
Hauptman PJ et al: Digitalis. Circulation 1999;99: 1265. [PM1D: 10069797] -
+
490 Essentials of Diagnosis &Treatment
Cyanide
• Essentials of Diagnosis
• Laboratory or industrial exposure (plastics, solvents, glues, fabrics),
smoke inhalation in fires
• By-product of the breakdown of nitroprusside, ingestion of cyanogenic
glycosides in some plant products (apricot pits, bitter
almonds)
• Absorbed rapidly by inhalation, through skin, or gastrointestinally
• Symptoms shortly after inhalation or ingestion; some compounds
(acetonitrile, a cosmetic nail remover) metabolize to hydrogen
cyanide, and symptoms may be delayed
• Dose dependent toxicity; headache, breathlessness, anxiousness,
nausea to confusion, shock, seizures, death
• Disrupts the ability of tissues to use oxygen; picture mimics
hypoxia, including profound lactic acidosis
• High oxygen saturation of venous blood; retinal vessels bright red
• Odor of bitter almonds on patient's breath or vomitus
• Differential Diagnosis
• Carbon monoxide poisoning
• Hydrogen sulfide poisoning
• Other sources of acidosis in suspected ingestion: methanol, ethylene
glycol, salicylates, iron, metformin
• Treatment
• Remove patient from the source of exposure, decontaminate skin;
100% oxygen by face mask; intensive care
For ingestion, gastric lavage, activated charcoal
• Inhaled amyl nitrite or intravenous sodium nitrite plus sodium
thiosulfate antidote; nitrites may exacerbate hypotension or cause
massive methemoglobinemia
• When the diagnosis is uncertain, significant hypotension contraindicates
empirical nitrite use; sodium thiosulfate alone (with
100% oxygen) may be effective
• Also hydroxocobalamin, dicobalt edetate, 4-dimethylaminophenol-
all given with thiosulfate
• Pearl
In a patient brought illfrom a theater fire with lactic acidosis. this is the
diagnosis.
Reference
Beasley OM et al: Cyanide poisoning: pathophysiology and treatment recommendations.
Occup Med (Lond) 1998;48:427. [PMID: 10024740]
Chapter 22 Poisoning 491
Isoniazid (INH)
+
• Essentials of Diagnosis
• Classic clinical triad: profound metabolic acidosis, hyperglycemia,
seizures
• Slurred speech, ataxia, coma, and seizures refractory to benzodiazepine
or barbiturate treatment
• Anticholinergic signs
• Chronic therapeutic use results in peripheral neuritis, tinnitus,
memory impairment, and hypersensitivity reactions
• Hepatic failure the most dangerous adverse reaction to chronic use
• Substantial genetic variability in the rate at which people metabolizeINH
• Differential Diagnosis
• Salicylate, cyanide, carbon monoxide, or anticholinergic overdose
• In the patient with seizures, acidosis, and coma, consider sepsis,
diabetic ketoacidosis, head trauma
• Hepatitis due to other cause
• Treatment
• Gastric lavage for large ingestion
• Activated charcoal
Pyridoxine (vitamin B6, I g for each g INH ingested; 5 g slow
intravenous empiric dose)
• Benzodiazepines as adjunct in seizure control
Supportive therapy for coma, hypotension
• Pearl
Ten to 20 percent ofpatients using 1NHfor chemoprophylaxis will have
elevated serum aminotransferases; 1% overall will progress to overt
hepatitis; the former have no symptoms, the latter have those oftypical
hepatitis.
Reference
Romero JA et al: Isoniazid overdose: recognition and management. Am Fam
Physician 1998;57:749. [PMlD: 9490997]
11II
+
492 Essentials of Diagnosis & Treatment
Lead
• Essentials of Diagnosis
• Results from chronic exposure; sources include solder, batteries,
homes built before 1974, artist's paint, gasoline
• Symptoms and signs include colicky abdominal pain, gum lead
line, constipation, headache, irritability, neuropathy, learning disorders
in children, episodes of gout
• Ataxia, confusion, obtundation, seizures
Peripheral blood smear may show basophilic stippling and hypochromic
microcytic anemia; renal insufficiency common
• Bone radiographs in children show lead bands; abdominal radiographs
show radiopaque material in intestine
• Blood lead> 10 ~g/dL toxic, > 70 ~g/dL severe
• Elevation of free erythrocyte protoporphyrin in chronic exposure
• Differential Diagnosis
• Other heavy metal toxicity (arsenic, mercury)
• Tricyclic antidepressant, anticholinergic, ethylene glycol, or carbon
monoxide exposure
• Other sources of encephalopathy: alcohol withdrawal, sedativehypnotic
medications, meningitis, encephalitis, hypoglycemia
• Medical causes of acute abdomen (eg, porphyria, sickle cell crisis)
• For chronic toxicity: depression, iron deficiency anemia, learning
disability
• Idiopathic gout
• Treatment
• Airway protection and ventilatory assistance as indicated; supportive
therapy for coma and seizures
• Activated charcoal for acute ingestion; consider whole bowel irrigation,
endoscopy, or surgical removal if a large lead-containing
object is visible on abdominal radiograph
• Chelation therapy hased on presentation and hlood lead levels
• Investigate the source and test other workers or family members
who might have been exposed
• Pearl
A cause ofnonsurgical acute abdomen in the Southeast, where illegal
whisky is made in car radiators.
Reference
Markowitz M: Lead poisoning: a disease for the next millennium. Curr Probl
Pediatr 2000:30:62. [PMlD: 10742920]
Chapter 22 Poisoning 493
Lithium
+
• Essentials of Diagnosis
• Classic triad: painless rigidity, tremor, hyperreflexia
• Multiple medications increase the risk of lithium toxicity (ACE
inhibitors, benzodiazepines, caffeine, loop diuretics, NSAIDs,
tricyclic antidepressants, haloperidol), as do renal failure, volume
depletion, gastroenteritis, and decreased sodium intake
• Worsening hand tremor, vertical or rotatory nystagmus, ataxia,
dysarthria, polyuria (nephrogenic diabetes insipidus), delirium,
stupor, rigidity, coma, seizures
• Acute ingestions cause more gastrointestinal symptoms (nausea,
vomiting, diarrhea, abdominal pain)
• Elevated serum lithium levels (> 1.5 meq/L); acute ingestions
lead to higher serum levels than chronic overdose
• U waves, flattened or inverted Twaves, ST depression, and bradycardia
may be seen on ECG
• Differential Diagnosis
• Neurologic disease (cerebrovascular accident, postictal state,
meningitis, parkinsonism, tardive dyskinesia)
Other psychotropic drug intoxication
• Neuroleptic malignant syndrome
Delirium
• Treatment
• Gastric lavage if soon after ingestion; whole bowel irrigation for
sustained-release preparations
Activated charcoal may be useful for other ingested medications;
sodium polystyrene sulfonate (Kayexalate) may be useful to bind
lithium
• Aggressive normal saline hydration with close management of
volume and electrolytes
Airway protection, ventilatory and hemodynamic support as
indicated
• Hemodialysis for severely symptomatic patients
• Pearl
Consider lithium like sodium: it is handled identically by the kidney,
and higher levels thus occur in volume depletion.
Reference
Timmer RT et al: Lithium intoxication. J Am Soc Nephro11999;1 0:666. [PMID:
10073618]
+
-
494 Essentials of Diagnosis & Treatment
Methanol, Ethylene Glycol, & Isopropanol
• Essentials of Diagnosis
• Methanol is found in solvents, record cleaning solutions, and paint
removers; ethylene glycol in antifreeze; isopropanol (rubbing
alcohol) in solvents, paint thinners
• Elevated serum osmolality and osmolar gap occur initially, followed
by development of anion gap metabolic acidosis
• Methanol and ethylene glycol poisoning progress to confusion,
convulsions, coma; ethylene glycol may produce tachycardia,
hypocalcemia, with tetany, prolonged QT
• Diplopia, blurred vision, visual field constriction, and blindness
with methanol; oxalate crystalluria and renal failure with ethylene
glycol; hemorrhagic gastritis and ketonemia without glycosuria or
hyperglycemia with isopropanol
• Urine may fluoresce under Wood's lamp in ethylene glycol ingestions
• Differential Diagnosis
• Ethanol ingestion
• Other causes of an anion gap acidosis (diabetic ketoacidosis, paraldehyde,
isoniazid, salicylates, iron, lactic acidosis, uremia)
• Hypoglycemia
• Treatment
• Thiamine, folate, pyridoxine, and naloxone if indicated; check
blood glucose, correct hypocalcemia and hypomagnesemia
• Gastric lavage appropriate only immediately after ingestion; activated
charcoal will not bind alcohols
• Maintain adequate airway and assist ventilation
• Supportive therapy for coma and seizures
• Sodium bicarbonate in presence of metabolic acidosis due to
methanol or ethylene glycol ingestion
• Ethanol infusion to level of 100-1 'i0 mg/dL to prevent metaholism
of methanol and ethylene glycol (not necessary for isopropanol);
alternatively, fomepizole (4-methylpyrazole) may be used
• Hemodialysis for severe toxicity
• Pearl
Ethylene glycol is colorless, not green; the color is an additive to discourage
ingestion ofanti-freeze.
Reference
Jones AL et al: Management of self poisoning. BMJ 1999;319:1313. [PMlD:
10574863]
Chapter 22 Poisoning 495
Methemoglobinemia
+
• Essentials of Diagnosis
• More common in infants, especially with exposure to nitrogenous
vegetables (spinach), well water with nitrates
• Drugs that can oxidize nonnal ferrous (Fez+) hemoglobin to abnormal
ferric (Fe3+) hemoglobin (methemoglobin) include local anesthetics
(lidocaine, benzocaine), aniline dyes, nitrates and niuites,
nitrogen oxides, chloroquine, trimethoprim, dapsone, and pyridium
• Methemoglobin cannot bind oxygen
Dizziness, nausea, headache, dyspnea, anxiety, tachycardia, and
weakness at low levels to myocardial ischemia, arrhythmias,
decreased mentation, seizures, coma
• Cyanosis unchanged by O2 ; saturation fixed at 85% even in
severe hypoxemia
• Definitive diagnosis is by co-oximetry (may be [Tom a venous
sample); routine blood gas analysis may be falsely normal
• Blood may appear chocolate brown (compare with normal blood);
urine may also turn brown
• Differential Diagnosis
• Hypoxia or ischemia
Sulfhemoglobinemia
• Carbon monoxide or hydrogen sulfide poisoning
• Treatment
• Gastric lavage and activated charcoal for recent, causative ingestion
or if offending agent is not known
Discontinue offending agent; high Aow oxygen
• Intravenous methylene blue for symptomatic patients with high
methemoglobin levels; patients with G6PD deficiency (higher
incidence in black males and patients of Mediterranean ancestry)
may develop hemolysis in response to methylene blue
• If methylene hlue therapy fails or is conLTaindicated, then exchange
transfusion or hyperbaric oxygen
• Pearl
Patients with preexisting impairment of OJ,ygen delivery (congestive
heartfailure, COPD, anemia) will be symptomatic at lower levels.
Reference
Wright RO et al: Methemoglobinemia: etiology, pharmacology, and clinical management.
Ann Emerg Med 1999;34:646. [pMID: 10533013]
+
496 Essentials of Diagnosis &Treatment
Opioids
• Essentials of Diagnosis
• Euphoria, drowsiness, and constricted pupils in mild intoxication
to somnolence, ataxia, hypotension, bradycardia, respiratory depression,
apnea, coma, and death with more severe intoxication
• Signs of intravenous drug abuse (needle marks, a tourniquet)
• Some (propoxyphene, tramadol, dextromethorphan, meperidine)
may cause seizures
• Noncardiogenic pulmonary edema
Detectable in urine, though not all opioids produce positive results
on general toxicology screens
• Meperidine or dextromethorphan plus monoamine oxidase inhibitor
may produce serotonin syndrome
• Differential Diagnosis
• Alcohol or sedative-hypnotic overdose
• Clonidine overdose
• Phenothiazine overdose
• Organophosphate or carbamate insecticide exposure
• Gamma-hydroxybutyrate overdose
• Congestive heart failure
Infectious or metabolic encephalopathy
• Hypoglycemia, hypoxia, postictal state
• Treatment
• Naloxone for suspected overdose
Gastric lavage for very large ingestions presenting within 1 hour
Activated charcoal for oral ingestion
Maintain adequate airway and assist ventilation, including intubation
Supportive therapy for coma, hypothermia, and hypotension
• Benzodiazepines for seizures
Acet.aminophen level
• Pearl
Be wary of unsuspected opioid toxicity in hospitalized patients taking
acetaminophen with codeine and renal insufficiency.
Reference
Lehmann KA: Opioids: overview on action, interaction and toxicity. Support
Care Cancer 1997;5:439. [PMID: 9406356]
Chapter 22 Poisoning 497
Salicylates
+
• Essentials of Diagnosis
• Many over-the-counter products contain salicylates, including
Pepto-Bismol, various liniments, oil of wintergreen
• Local gastric irritation, direct stimulation of central nervous system
respiratory center, skeletal muscle metabolism, enhanced
lipolysis, and uncoupled oxidative phosphorylation
• Mild acute ingestion: nausea, vomiting, gastritis
• Moderate intoxication: hyperpnea, diaphoresis, tachycardia, tinnitus,
elevated anion gap metabolic acidosis
• Severe intoxication: agitation, confusion, proteinuria, hyperventilation,
seizures, pulmonary edema, cardiovascular collapse, hyperthermia,
hypoprothrombinemia
• Chronic pediatric ingestion: hyperventilation, volume depletion,
acidosis, hypokalemia, metabolic acidosis, respiratory alkalosis;
in adults: hyperventilation, confusion, tremor, paranoia, memory
deficits
• Differential Diagnosis
• Carbon monoxide poisoning
Any cause of anion gap metabolic acidosis (eg, methanol or ethylene
glycol ingestion)
• Treatment
• Elevated serum salicylate level; treatment should always consider
both serum level and clinical condition
• Gastrointestinal lavage or whole bowel irrigation for early, large,
or sustained-release ingestions
• Activated charcoal
Maintain adequate airway and assist ventilation
• Supportive therapy for coma, hyperthermia, hypotension, and
seizures; correct hypoglycemia and hypokalemia
• TnLTavenous Auid resuscit.ation wit.h normal saline; urinary alkalinization
with sodium bicarbonate to enhance salicylate excretion
• Hemodialysis for severe metabolic acidosis, markedly altered
mental status, or clinical deterioration despite supportive care
• Pearl
The classic triad ofsalicylate poisoning: wide anion-gap acidosis, contraction
metabolic alkalosis, respiratory alkalosis.
Reference
Sporer KA et al: Acetaminophen and salicylate serum levels in patients with suicidal
ingestion or altered mental status. Am J Emerg Med 1996;14:443.
[PMID: 8765104]
+
498 Essentials of Diagnosis & Treatment
Theophylline
• Essentials of Diagnosis
• Mild intoxication: nausea, vomiting, tachycardia, tremulousness
• Severe intoxication: tachyarrhythmias (premature atrial and ventricular
contractions, multifocal atrial tachyarrhythmia, atrial fibrillation
and flutter, runs of ventricular tachycardia), hypokalemia,
hyperglycemia, metabolic acidosis, hallucinations, hypotension,
seizures
• Chronic intoxication: vomiting, tachycardia, and seizures, but typically
no hypokalemia or hyperglycemia
• Elevated serum theophylline concentration
• Differential Diagnosis
• Caffeine overdose
• Iron toxicity
• Sympathomimetic poisoning
• Anticholinergic toxicity
• Thyroid storm
• Alcohol or other drug withdrawal
• Treatment
• Gastric lavage or whole bowel irrigation early in large or sustainedrelease
ingestions
• Activated charcoal; repeated doses may enhance elimination
• Ranitidine for vomiting
• Oxygen; maintain adequate airway and assist ventilation
• Monitor for arrhythmias; correct hypokalemia
• Treat seizures with benzodiazepines
Hypotension and tachycardia may respond to beta-blockade
(esmolol,labetalol)
• Hemodialysis or hemoperfusion for patients with status epilepticus
or markedly elevated serum theophylline levels (> 100
mg/mL after acute overdose or > ()() mg/mL with chronic intoxication)
• Pearl
Inappropriate sinus tachycardia in a patient with COPD may be the
only clue to the diagnosis: once seizures occur, the prognosis worsens
appreciably.
Reference
Vassallo R et al: Theophylline: recent advances in the understanding of its mode
of action and uses in clinical practice. Mayo Clinic Proc 1998:73:346. [PMlD:
9559039]
Index
Note: Numbers in italics signify main entries.
A
Abdomen, surgical, 300. See also
Acute abdomen
Abdominal pain, 406, 451
Abortion
spontaneous, 400, 408
threatened, 255
Abscess
brain, 204, 307, 309, 310,311,
429,442
dental, 475, 480
epidural,319
of head, 305
hepatic, 97, 97, 98, 245
lung, 48, 50, 52, 53,66,71,240,
263
pancreatic, 425
perirectal, 283
pyogenic, 98
renal, 437
retropharyngeal, 431,477
subareolar, 413
tubo-ovarian, 406
visceral, 154
Acanthosis nigricans, 396
Acetaminophen poisoning, 90, 481
Achalasia, 64, 65, 66,67,68,69,
261,420,432
Achalasia, cricopharyngeal, 411
Acid, loss of, 281
Acidemia, 270
Acidosis, 104, 490, 491
anion gap, 497
lactic, 195, 280, 490, 494
metabolic, 280, 374
renal tubular, 280, 299
respiratory, 278, 374
Acne rosacea, 364
Acne vulgaris, 364, 365, 367
Acrochordon, 375, 376
Acrodermatitis enteropathica, 371
Acromegaly, 172, 175,193,194
Actinic keratosis, 375, 381,382, 383,
384
Actinomycosis, 239, 240
Acute abdomen, 113, 119,492
Acute lymphoblastic leukemia
(ALL),436
Acute respiratory distress syndrome
(ARDS),37
Addison's disease, 174, 179, 186,485
Adenitis
cervical, 239
mesenteric, 77, 423
submandibular, 480
Adenocarcinoma, 68
of colon, 83, 84
in gastric ulcer, 262
of Iddney, 260
of prostate, 257
of rectum, 84
Adenomyosis, 400, 401, 404, 405,
414
Adenopathy. See also
Lymphadenopathy
bilateral axillary, 238
hilar, 132
Adhesions, intestinal, 421
Adjustment disorder, 334, 335, 342
Adrenal gland, tumor of, 281
Adrenal hyperplasia, 190
Adrenal insufficiency, 179, 186, 186,
266,267,269,272,432
Afibrinogenemia, 142
Agranulocytosis, 126
AIDS, 109, 138, 140,367,374
dementia with, 324
lung infections related to, 40
Airway obstruction, 278. See also
Foreign body
Akathisia, 332
Albright's syndrome, 450
499
Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use.
500 Index
+
Albuminuria, 304
Alcohol abuse, 63, 140
Alcohol dependence, 344
Alcoholism, 114,273,275,277
anemia in, 122
chronic, 180, 187
Alcohol overdose, 496
Alcohol withdrawal, 345,483,492,
498
Alkalemia, 271
Alkalosis
metabolic, 281, 497
respiratory, 277,279,497
Alkaptonuria, 452
Allergic bronchopulmonary
aspergillosis, 47, 61
Allergic contact dermatitis, 352, 369
Allergic granulomatosis, 155
Allergy
drug, 199, 202, 435
food,439
Alopecia
androgenetic, 392
androgenic, 393
Alopecia areata, 392, 393
Alpha-adrenergic blockers, 417
Alpha-agonism, unopposed, 486
Alpha-thalassemia, 117
Alpha-thalassemia trait, 118
Alveolar hemorrhage, diffuse, 37
Alzheimer's disease, 433. See also
Dementia
Amebiasis, 229
Amebic dysentery, 228, 230
Ameboma, 81, 244
Amenorrhea, 409, 416
Amesotheliocytosis,38
Aminoglycosides, 273, 277, 320
Amiodarone toxicity, 452
Amphetamine poisoning, 482
Amphotericin B, 277
Ampulla of Vater, carcinoma of,
100, 247
Amyloidosis, 81,136,149,171,179,
242
Amyotrophic lateral sclerosis (AL5),
205,320
Anal fissure, 85
Analgesics, over-the-counter, 294
Anaphylactic transfusion reaction, 113
Anaphylactoid purpura, 443
Anaphylaxis, 22, 46
Androgen ingestion, exogenous, 188
Androgen insensitivity, 189
Anemia, 363,495
acute hemolytic, 485
aplastic, 125,126, 127, 128, 135,
140,436
autoimmune hemolytic, 111, 112,
114,436
of chronic disease, 106, 107, 122,
133
congenital nonspherocytic, 116
drug-induced hemolytic, 112
hemolytic, 115, 123, 132
hyperchromic microcytic, 114
iron deficiency, 67,106, 107, 114,
115,117,118,122,123,131,
244,492
of liver disease, 117
megaloblastic, 11 1
microangiopathic hemolytic, I08,
109, II 0,112
nonspherocytic hemolytic, III
pernicious, 315
retinopathy of, 462, 467, 595
with rouleau formation, 137
sepsis-induced, IU~
sickle cell, 119, 120, 121,399,
492,595
sideroblastic, 106, 107, Ill, 117,
118,122,133
Aneurysm
femoral artery, 426
intracranial,308, 309
ruptured berry, 308
Aneurysm, aortic
abdominal, 86, 418, 425
mycotic, 228
mptured, 22
Angina
Ludwig's, 46
pectoris, 1, 13, 14, 15, 64, 65, 72,
173,322
Prinzmetal's, 14
refractory, 150
stable, 150
unstable, 14, 15, 16
Angioedema, 389
ACE inhibitor-induced, 389
complement-mediated, 389
Angiomatosis, bacillary, 380
Angiitis, allergic, 155
Anion gap acidosis, 494, 497
Ankylosing spondylitis, 162, 163,
164, 165,452
Index 501
Anorectal dysfunction, 326
Anorexia nervosa, 174, 186,362,409
Anosmia, 189
Anovulation, 400
AntJlrax, 222
Antiarrhyilimics, 484
Anticholinergic exposure, 152,287,
417,492
Anticholinergic poisoning, 482, 491,
498
Antidepressant overdose, 483, 484.
See also Tricyclic antidepressants
Anti-glomerular basement membrane
nephritis, 157,290,292,293
Antihistamines, 484
Antihypertensives, 347
Antiphospholipid antibody
syndrome,160
(X,-Antiprotease dificiency, 44, 45
Antipsychotics, 152
Antral web, 432
Anxiety, 180,279,332,414
Anxiety disorders, 333, 334, 334,
335,336,337,33~,34U,342,
344,345
Aortic coarctation, 3, 34
Aortic dissection, I, 15,16,22,30,
71,267.455
Aortic regurgitation, 10, 11, 455
Aortic stenosis,S, 6, 8, 9, 12,27,28
Aortitis, syphilitic, 159
Aortoenteric fistula, 418
Aperistalsis, 65, 66, 67
Aphiliosis, oral, 372
Aphthous ulcers, 198
Aplasia, red cell, 125
Appendicitis, 77, 97, 98, 99, 300.
406,41U,422,423,424,427,
428,444,448,451
Argylia, 452
Arnold-Chimi malformation, 316
Arrhythmia, 489
Arsenic poisoning, 485, 492
Arterial insufficiency, 399
Arterial occlusion, lower extremity,
430
Arteriovenous fistulas, dural, 309
AI1eriovenous malformations, 41,
308,309
Arthritides, crystal-induced, 143
Arthritis
acute bacterial, 168
degenerative, 316
gonococcal, 164. 166, 167
infective, 438
with inflammatory bowel disease,
162,163,164,165
juvenile rheumatoid, 29, 436, 438,
441,443
nongonococcal bacterial, 167
psoriatic, 162, 163, 164, 165
reactive, 162, 163,164, 165,167,
236,237,354,369,371,438,
456
red cell aplasia and, 125
rheumatoid, 29, 80,143,144, 145,
146,148, ISO, 152, 154, 158,
162,163,164,165,170,172,
177
rubella-associated,2UO
septic, 144,166
Ariliropailiy, hydroxyapatite, 145
Asbestosis, 53, 54, 58, 59
Ascites, 103, 254
Aspergillosis, 42
allergic bronchopulmonary, 47,61
invasive, 47
Aspiration, foreign body, 42, 46, 56,
224
Aspirin ingestion, 141. See also
Salicylate poisoning
Asthma, 22, 42,43,44,45,46,47,
49,56,61,62,333,434,459
Astrocytoma, 265
Atelectasis, 38, 56
Ailierosclerosis, 159, 160
Aililete's heart, 27
Atopic dermatitis, 349, 35 1,352,355,
363,378
Atrial fibrillation, 17, 18,19,21
Atrial flutter, 17, 18, 19,21
Atrial myoma, 36
Atrial septal defect, 4, 8,9, 12
Atrioventricular block, 23
Auditory tube, obstruction of, 472
Autoimmune diseases, 36, 57, 131,
152,467
Axillae, hidradenitis suppurativa of,
367
Azotemia, 288, 289, 294, 296, 297,
298. See also Uremia
B
Bacillary dysentery, 229
502 Index
Bacillus anthracis. 222
Back pain, 414, 418
Bacteremia, 113,279
Bacterial infections, 198,374,435,
See also Infections
Bacteriuria, asymptomatic, 301
Bagassosis, 62
Baker cyst, ruptured, 35
Baldness, common, 392, See also
Alopecia
BalTett's esophagus, 69
Bartonella henselae, 238
Bartter's syndrome, 271 , 281
Basal cell carcinoma, 374, 381,383,
384,385,386
Beer potomania, 177
Beh<;:et's syndrome, 161, 236,237
Bell's palsy, 318
Benign prostatic hyperplasia (BPH),
162,257,287
Bereavement, 342
Berger's disease, 292
Beriberi, 215, 366
Belylliosis,55
Beta-blocker poisoning, 486, 487,
489
Beta thalassemia, 117, 118, 120
Bicarbonate, exogenous, 281
Bile ducts, malignant tumors of, 246
Biliary stricture, 100,246
Biliary tract
carcinoma of, 101
obstruction of, 95
Bipolar disorder, 340, 342, 343
Bladder
cancer of, 259, 282, 414
Kaposi's sarcoma of, 259
neurogenic, 257,287
Bleeding, abnormal uterine, 400,404.
See also Hemorrhage
Blepharitis, 365, 639
Blindness, 466
Blood loss, 112, 400, See also
Hemorrhage
Body dysmorphic disorder, 348
Boerhaave's syndrome, I, 7I
Bone
idiopathic avascular necrosis of,
453
malignancy to, 453
tumors of, 438
Bone marrow
infiltration of, 127, 135
metastatic malignancy to, 128, 131
neoplastic process of, 124
Bordetella pertussis, 224
BOITelliosis, 207, 208
Botulism, 221,223,317,320
infantile, 449
wound, 221
Bowel disease
arthritis associated with, 147, 165
functional. 76. 244, 262
inflammatory, 79, 81, 82, 88, 95,
147,163,164,228,414,423,
424,427,438
initable bowel syndrome, 76, 79,
82,87,262,414
Bowenoid papulosis, 376
Bowen's disease, 39, 382
Brachial plexus neuropathy, 173
Brain
abscess of, 204, 307, 309, 310,
311,429,442
tumor of, 307,429
Brazilian pemphigus, 388
Breakbone fever, 207
Breast
cancer of, 248, 249, 311, 412
fibrocystic disease of, 248, 412
tumors of, 197
Breathing disorders, sleep-related, 63
Bronchial compression, 46
Bronchiectasis, 43, 44, 45, 47, 48,
52
Bronchiolitis, 46, 434
Bronchiolitis obliterans with
organizing pneumonia (BOOP),
37,4~ 50,51,54,60,61
Bronchitis, 216, 224
Brucellosis, 213, 227,232
Budd-Chiari syndrome, 96
Buerger's disease, 160, 292
Bulbar syringomyelia, 457
Bulimia, 348
Burns, 114,266,270
C
Cachexia, 174
Cafe au lait spot, 386
Caffeine overdose, 498
Calcium antagonist poisoning, 486,
487
Calcium channel blockers, 326, 487,
489
Index 503
+
Calcium oxalate deposition disease,
144, 145
Calcium phosphate disease, 145
Calcium pyrophosphate dihydrate
deposition disease, /45
Calculi
renal, 260, 444
urinary, 259, 282, 284, 406, 410,
414
Calf strain or contusion, 35
Calymmnrobaclerium granulomatis,
237
Campylobacter dysentery, 228
Campylobacter enteritis, 230
Campylobacter infection, 229
Campylobacterjejuni, 230
Cancer. See also Carcinoma
bladder, 282
of breast, 31 '1
of cervix, 25/
lung, 52, 239
prostate, 287
skin, 328
of thyroid, 256
Candidiasis, 223. 357
chronic mucocutaneous, 371
cutaneous, 354, 37/
oral, 371
Carbamate insecticide exposure, 496
Carbamazepine, 211,484
Carbon monoxide poisoning, 312,
48~490,491,492,495,497
Carboxyhemoglobin, 130
Carbuncles, 367
Carcinoid syndrome, 2, 365
Carcinoma. See also Malignancy
of ampulla of Vater, 247
ampullary,246
basal cell, 374, 381,383, 384,385,
386
bile duct, 95
of biliary tree, '101
of bladder, 259, 414
breast, 248, 249, 412
bronchogenic, 43, 52, 53, 263
of cervix, 250, 400, 402, 403
choriocarcinoma, 255
of colon or small bowel, 81
colorectal,244, 254,424
of common duct, 100
endometrial,252
esophageal, 66
gastric, 76
of head and neck, 243
hepatocellular, 104,105,245
inflammatory, 413
in-situ, 39, 382
metastatic, 185
nasopharyngeal, 471
pancreatic, 87, 90, I DO, 10 I, 246,
247,425
of prostate, 257
rectal. 407
renal cell, 260, 298
sebaceous cell, 469
sebaceous gland, 639
of sinus, 475
squamous cell, 375, 376, 381,382,
383,384
of stomach, 262
of thyroid, 178, 181
transitional cell, 259
uterine,4DO
of vulva, 253
Cardiac emboli, 429
Cardiac failure, 103. See also Heart
failure
Cardiac glycosides, 489
Cardiac tamponade, 3/, 32
Cardioesophageal fistula, 69
Cardiomyopathy, 5, 8, 9, 28
dilated, 26, 96
hypertrophic obstructive, 27, 28
restrictive, 27, 31, 32, 96
Carotid artery
disease, 429
dissection, 429
Takayasu's arteritis of, 154
Carotid distribution stroke, 318
Carotid plaque, with embolic
amaurosis fugax, 154
Carotid pulse, rapid, 8
Carpal tunnel syndrome, 16,173
Catabolic illness, 180,275
Cataract, 46/
Cat-scratch disease, 138,139, 233,
238
Caustic ingestion, 71
Celiac disease, 371
Celiac sprue, 78, 80
Cellulitis, 35,144,168,219,366
facial,480
infectious, 215
preseptal,469
Central nervous system (CNS)
disease, 192,279, 343
504 Index
Cerebellar ataxia, 315
Cerebellar degeneration, alcoholic,
323
Cerebral circulation ischemia, 221
Cerebral infarction, 310
Cerebrovascular accident, 196, 493
Cervical intraepithelial neoplasia
(CIN),250
Cervical radiculopathy, 13, 14, 15,
16,173
Cervical stenosis, 401
Cervicitis, 235, 250, 251,400,402,
403,415
Cervix
aborted pregnancy of, 251
cancer of, 251,400,402,403,407,
408
carcinoma in situ of, 250
dysplasia of, 4/5
Chalazion, 469
Chancroid, 236,251,372,402
Chemoprophylaxis, INH for, 491
Chest pain, 482
Chest wall injury, 176
Chickenpox,2U2
Child abuse, 443
Chlamydial infections, 85
Chloasma faciei, 395
Cholangiocarcinoma, 83, 246
Cholangitis, 86, 93
Cholangitis, sclerosing, 83, 92, 95,
10/
Cholecystitis, 13, 14, 15, 16,30,64,
73,74,75,76,86,93,97,98,
99,422,423,427,42~451
Choledocholithiasis, 90, 100, 101,
246,247
Cholelithiasis, 93, 97, 98, 99, 99
Cholera, 121
Cholera, pancreatic, 231
Cholestasis, drug-induced, 95,101,
246,247
Cholesteatoma, 445
Cholesterol atheroembolic disease,
153,160,430
Chondrocalcinosis, 145
Choriocarcinoma, 255
Choriomeningitis, lymphocytic, 204,
206
Chorioretinitis, 459
Choroidal detachment, 464
Choroidal neovascularization, 466
Christmas disease, 142
Chromosome abnormalities, 433
Chronic fatigue syndrome, 170, 179
Chronic lung disease, 329
Chronic obstructive pulmonary
disease (COPD), 2, 4, 18, 19,
42,43,44,47,48,63,278,333,
495,498
Chrysiasis, 452
Churg-Strauss vasculitis, 42, 47, 61,
153,155, 157
Circadian rhythms, disordered, 332
Circu lation, hypervisicosity of, 231
Cirrhosis, 24, 93, 94, 96, 120,121,
176,203,246,247,269,291
alcoholic, 91
with ascites, 32
end-stage, 279
normal hematocrit in, 105
with portal hypertension, 57
primary biliary, 92, 94,95
Cisplatin,277
Clonidine overdose, 489, 496
Clonorchis sinensis infection, 101
Clostridial myonecrosis, 219
Clostridium botulinum, 221
Clostridium difficile colitis, 88
Clostridium rerani, 220
Coagulation disorders, 400
Coarctation of aorta, 3, 34
Cocaine overdose, 482, 484
Coccidioidomycosis, 55, 58, 240,
311
Cognitive changes, age-related, 324
Cold, common, 479
Cold agglutinin disease, I I I
Colic, 439
Colitis, 424, 427
amebic, 83, 98
bacterial, 83
Clostridium difficile, 88
collagenous, 83
granulomatous, 83
ischemic, 83
parasitic, 88
pseudomembranous, 83
radiation, 83
ulcerative, 77, 80, 83, 101,229,
230,246
viral, 88
Collagen-vascular disease, 62, 595
Colon
acute pseudo-obstruction of, 89
carcinoma of, 244, 424
Index 505
obstruction of, 421, 424
polyps of, 84
Colonic stricture, benign, 83
Colorado tick fever, 208
Coma, 196, 491
Combined system disease, 319
Condyloma latum, 376
Condylomata acuminata, 376
Confusion, postictal, 104
Congestive hemt failure, 24, 25, 35,
36,40,42,43,44,51,60,94,
179,269,291,329,459,495,
496
Conjunctivitis, 365, 456, 456,457,
458,460
Connective tissue disease, 150, 169
Consolidation, lobar, 38
Constipation, 326,414,447,449
Contact dem1atitis, 349, 350, 351,
352,355,363,366,371,403
allergic, 352, 369
photoallergic, 359
phototoxic, 359
Cormorbid disease, 332
Comea
abrasion of, 456, 457, 458, 460
ulceration of, 457
Coronary m·tery disease, 25. See also
Angina
Coronary syndromes, 13
Coronary vasospasm, 15, 482
Cor pulmonale, 33
Cor triatriatum, 7, 36
Corynebacterium diphtheriae, 223
Costochondritis. See Tiet7-e's
syndrome
Cough
ACE-induced, 43
chronic, 43
postinfectious, 43
Coumarin necrosis, 398
Coxiella bumelfi, 213
Coxsackievirus infection, 372
Creutzfeldt-Jakob disease, 324
Cricopharyngeal achalasia, 411
Crohn's disease, 77, 78, 80, 83, 85,
147,239,253
Croup, 46, 49, 431, 434,477
Cryoglobulinemia, 149, 153, 156,
158
Cryoglobulins, 399
Cryptococcal infection, cutaneous,
374
Cryptococcosis, 311
Cushing's syndrome, 3, 34, 187, 188,
189, 190, 193, 194, 343
Cyanide poisoning, 488, 490, 491
Cystadenoma, tracheal, 46
Cystic fibrosis, 45
Cystitis, 259, 283, 300,406,414
Cysts
amebic liver, 245
lymphoepithelial,480
ovari3J1, 424
renal, 260, 298
ruptured corpus ]uteum, 410
ruptured ovarian, 406
simple, 260
thyroglossal duct, 256
twisted ovarian, 423
Cytomegalovirus (CMV) disease,
126,201, 211,436
Cytopenias, 133
D
Dacryocystitis, 456, 475
Dandruff, 351
Dandy fever, 207
Darier's disease, 369
Deep venous thrombosis, 35, 430
Degenerative joint disease (DJD),
143, 145, 146
Dehydration, 231,266
Delirium, 324, 325, 342, 345,493
Delirium tremens, 104, 325, 345
Delta wave, 20
Dementia, 313, 323, 324, 329, 342
Demodex folliculitis, 365
Dengue, 207, 210
Dentures, ill-fitting, 329
Depressant drug ingestion, 488
Depressants, 278
Depression, 63, 154, 170,179, 187,
312, 324, 325, 332, 347,409,
414,492
Depressive disorder, major, 333,
334,335,337,338,340,342,
348
Dermatitis
allergic contact, 352, 369
atopic, 349, 351, 352, 355, 363,
378
contact, 349, 350, 351, 352, 355,
359,363,366,371,403
eczematoid, 253
506 Index
Dermatitis (continued)
eczematous, 349
exfoliative, 355
herpetiformis, 377, 378, 387
nummular, 368
perioral, 364, 365
photoallergic contact, 359
phototoxic contact, 359
reactive, 253
sebOiTheic, 349, 351, 352,353,
354,355,365,368,370,371,
377,391
stasis, 363
xerotic, 350
Dermatofibroma, 380, 386
Dermatomyositis, 151, 359,365,
438
Dermatophytid reaction, 352
Dermatophytosis, 371
Dermatoses, 370
acute febrile neutrophilic, 379,
398
eczematous, 356
linear IgA, 387, 388
neutrophilic, 360
papulosa nigra, 381
Dermoid, 468
Detrusor overactivity, 414
Diabetes, 203
external otitis in, 478
impending, 396
retinopathy of, 465
type 2, 266
Diabetes insipidus, 177, 193, 194,
196,268
Diabetes mellitus, 87, 177, 187,329,
347,447,448
type I, 193
type 2, 194
Diabetic ketoacidosis, 193,195,280,
491,494
Diabetic neuropathy, 399
Dialysis, 103
Diarrhea, 75, 269, 271,277,280,
299,326
antibiotic-associated, 83, 88
bacterial, 88
chronic, 20 I
parasitic, 88
small intestinal, 231
viral, 88
Diffuse idiopathic skeletal
hyperostosis (DISH), 162
Digitalis intoxication, 23, 270, 486,
487,489
Digoxin, 329
Diphtheria, 214, 223, 223,317
Disaccharidase deficiency, 79
Discoid lupus erythematosus, 357
Disk problems, 414
Disseminated intravascular
coagulation (DIe), 108, 109,
110, 140, 142
Dissociative disorders, 340
Diuresis, osmotic, 177
Diuretic overuse, 281
Diuretics, 190, 271,273,277,417,
447
Diurnal variation, in intraocular
pressure, 459
Diverticular disease, 82, 83, 244, 414
Diverticulitis, 77, 406, 424,427,451
Diverticulosis, jejunal, 78
Dock's murmur, 10
Dowling-Degos' disease, 396
Down's syndrome, 433
Doxorubicin toxicity, 26
Dressler's syndrome, 56
Drug abuse, intravenous
embolization from, 465, 467
Drug allergy, 199,202,435
Drug eruption, 353, 355, 356, 358
acneiform, 367
fixed, 360, 366
generalized bullous fixed, 361
lichenoid, 357
morbilliform, 361
photosensitive, 359
Drug hypersensitivity syndrome, 358
Drug reactions, bullous, 361
Drug toxicity, 140,214,241,289,
320,324,329, 332. See also
specific drugs
Drusen, prominent, 466
Duodenal ulcer, 74, 86,87
Dysentery, 230
amebic, 228, 230
bacillary, 229
shigella, 228
Dysequilibrium,330
Dysfibrinogenemia, 141, 142
DysmenOiThea, 401, 405
Dysphagia, 261, 329, 420
Dysplasia, cervical, 250,402,415
Dysplastic nevus, 386
Dysthymic disorder, 342
Index 507
E
E coli infection, 110,228,231
Eales' disease, 467, 595
Eating disorders, 348
Eaton-Lambert syndrome, ·151
Ecstasy overdose, 482
Ectopia lentis, 454, 461
Eczema, 371, 377
herpelicum, 349
nummular, 350, 354
Eczematous dermatitis, 349
Edema, angioneurotic, 431
Ehlers-Danlos syndrome, 455
Ehrlichiosis, 212
Eisenmenger's syndrome, 2, 4, 6,
33
Emphysema, congenital, 45
Empty sella syndrome, 174
Empyema, 264, 3 10
Encephalitides, 204
Encephalitis, 198, 199,204,209,
310,323,442,446,492
Encephalopathy, 492
hepatic, 104
infectious, 496
metabolic, 496
Endocarditis, 5, 29, 148, 154, 158,
201,2/2,260,293,310
culture-negative, 147,213
gonococcal, 235
infective, 36, 161, 166, 167,227,
232,290,292
Streptococcus bovis, 244
subacute, 36, 153
Endocrinopathies, 26, 333, 334,343
Endolymphatic hydrops, 473, 474
Endometriosis, 39, 254, 401, 405,
414,423
Endometritis, 40 I, 406
Endometrium, carcinoma of, 252
Enteric fever, 227
Enteritis, campylobacter, 230
Enterovirus infection, 435
Enuresis, 447
Eosinophilic pulmonary syndromes,
61
Epidelmodysplasia verruciformis,
375
Epidelmolysis bullosa acquisita, 387,
388
Epididymitis, 258, 282, 283, 285,
286,423
Epigastric mass, 432
Epiglottitis, 431, 477
Epilepsy, idiopathic, 306
Epiphrenic diverticulum, 411
Episcleritis,456
Epstein-Barr virus (EBV) infection,
199,200,201,211.436
Erysipelas, 366
Erythema induratum, 397
Erythema migrans, 389, 390
Erythema multifOime. 161.242.357.
360,371,372,388,389,397
major, 358, 361,36/
minor, 361,379
secondary, 390
Erythema nodosum, 242, 366, 397
Erythrasma, 371
Erythrocytosis. 130
Erythroderma, 355
Erythropoietin-secreting tumors, 130
Esophageal diverticulum. 67, 261,
420
Esophageal pelforation
emetogenic, 71
instrumental, 71
Esophageal spasm, 13, 14, 15, 16,
64,65,66
Esophageal stenosis, 432
Esophageal stricture, 66, 67, 72, 261,
411,420
Esophageal varices, 70
Esophageal web, 67,68,69,261,
411,420
Esophagitis, 75, 76, 102
infectious, 70
pill, 70, 71
reflux, 70, 74
Esophagoduodenoscopy,411
Esophagus
benign stricture of, 68, 69
foreign bodies in, 72, 431
malignant tumors of, 26/, 411,
420
Estrogens, exogenous, 252
Ethanol ingestion, 494
Ethylene glycol poisoning, 492, 494
Euthyroid, 181
Ewing's sarcoma, 168
Exanthema subitum, 435
Exanthems
acute, 199,200
viral, 207, 208, 214, 353, 358
Extremities, pyogenic infection of,
236
508 Index
+
F
Facial pain, 382
Facial pain syndrome, 322
Facial paresis, idiopathic, 318
Factitious disorder, 338, 339
Factor deficiencies, 142
Falls, 330
Fanconi's syndrome, 193, 194,299
Fasciitis
early necrotizing, 366
eosinophilic, 149, 150, /69
Fat necrosis, 248,412, 413
Fat pad, 41
Fatly Ii ver, 93
Febrile seizures, 446. See also
Seizures
Felty'S syndrome, 126
Fibroadenoma, 412
Fibrocystic disease, 248, 4/2
Fibroid tumor, 404
Fibromuscular hyperplasia, 429
Fibromyalgia, 170
Fibromyoma, 404
Fibrosis
drug-induced,54
radiation, 429
retroperitoneal, 254
Fibrositis, 170
Fibrous dysplasia, 185
Fissura-in-ano,85
Fistula
aortoenteric, 418
urinary, 417
Fitz-Hugh and Curtis syndrome, 406
Flat gut, 78
Fluid loss, 266, 268, See also
Dehydration
Fogo selvagem, 388
Folic acid deficiency, 123,124
Folliculitis, 367, 398
demodex, 365
eosinophilic, 364, 367
fungal,367
gram-negative, 364, 367
herpes, 367
hot tub, 367
nonbactelial,367
pseudofolliculitis, 364, 367
staphylococcal, 364
Food allergy, 439
Food poisoning, 229, 230
Foreign bodies
aspiration of, 42, 46, 224,434
in cornea, 457
in ear, 445
in esophagus, 72
inhaled,49
intraocular, 460
in larynx, 431, 477
in throat, 431
in vagina, 403
Foscamet, 273
Francisella lularensis, 233
Fungal folliculitis, 367
Fungal infection, 40, 53, 59, 222,371
Furuncles, 367
G
Gaisbock's syndrome, 130
Gait impairment, 323, 330
Galliverden's phenomenon, 9
Gallstones, 87, 99
Gamma-hydrox ybutyrate overdose,
496
Gammopathy, benign monoclonal,
136,137
Gangrene
clostridial,366
gas, 219
Gas gangrene, 2/9
Gastric outlet obstruction, 281
Gastric ulcer, 74, 75, 76, 262
Gastrinoma, 75
Gastritis, 70, 73, 74,75,76,86, 102,
262
Gastroenteritis, 448
acute, 444
salmonella, 228
viral, 228, 229, 230, 231
Gastroesophageal junction, mucosal
laceration of, 70
Gastroesophageal reflux disease, 43,
64, 432, See also Reflux disease
Gastrointestinal fluid losses, 266
Gastrointestinal malformation,
congenital,449
Gastropathy, portal hypertensive, 102
Gaucher's disease, 453
Generalized anxiety disorder, 334,
336,342
Genital lesions, 360
herpes, 372
warts, 376
Genitourinary anomalies, congenital,
447
Index 509
Genitourinary tract
tuberculosis of, 282
tumor of, 284
Geographic tongue, 371
Gestational trophoblastic neoplasia,
255
Giant cell arteritis, 154, 159, 305,
322,429
Giardiasis, 79
Gigantism, 175
Gingivostomatitis, necrotizing, 223
Gitelman's syndrome, 271,281
Glaucoma
acute (angle-closure), 456, 457,
458
open-angle (chronic), 459
Glioblastoma, 265
Gliosis, brain stem, 322
Globus hystericus, 261,420
Glomerulonephritis, 148,158, 215,
259,294,302,304
acute, 290
membranoproliferative,290
postinfectious, 293
poststreptococcal, 2\12
unexplained membranous, 291
Glossopharyngeal neuralgia, 322
Glucocorticoids, 187, 193, 194
Gluten enteropathy, 363
Glycogen storage disease, 151
Glycoside ingestion, 486
Glycosuria, nondiabetic, 193, 194
Goiter
diffuse toxic, 178, 181
endemic, 181
nodular, 178
simple, 178
substernal, 46, 434
Gonococcal arthritis, 164, 166, 167
Gonococcal infection, disseminated,
29
Gonococcemia, 156,212
Gonorrhea, 235
Goodpasture's syndrome, 157,290,
292,293
Gougerot and Carteaud,
papillomatosis of, 396
Gout, 143, 144, 145, 146, 172,492
144
Graft-versus-host disease, 149, 150,
358,361
Graham Steell murmur, 10
Granuloma, 41
annulare, 368, 389, 390
inguinale, 237,251,372,402
pyogenic, 380, 385, 469
Granulomatosis
allergic, 155
lymphomatoid,139
Granulomatous disease and
disorders, 147, 183
infiltrative, 123, 124
noninfectious, 263
Graves' disease, 178, 181
Groin, hidradenitis suppurativa of,
367
Growth retardation, 432
Growth spurt, physiologic, 175
Guillain-Barre syndrome, 205, 208,
221,278,317,321,451,485
Gynecomastia, 197, 249
H
Haemophilus ducreyi, 236
HamaItoma, 41, 263
Hand-foot-and-mouth disease, 198
Hansen's disease (leprosy), 242, 356,
370,390,394
Hay fever, 476
Head, carcinoma of, 243
Headache, 488
carbon monoxide, 488
cluster, 305,475
migraine, 305, 308, 311
tension, 305, 308
vascular, 311
Head trauma, 196,491
neurologic syndrome secondary
to, 335
unsuspected, 241
Hearing impairment, 327
Hew block, atrioventricular, 23
Hew disease
congenital, 57
hypertensive, 27, 28
ischemic, 27, 28, 57, 73
rheumatic, I I, 452
Heart failure. See also Congestive
heart failure
left, 24
right, 24
Heat rash, 367
Heat stroke, 482, 483
Heavy metal poisoning, 317,451,
485,492
510 Index
Heel pain, chronic, 372
Helicobacter pylori, 64,73
HELLP syndrome, 109, 110
Hemangioblastoma, cerebellar, 265
Hematoma
epidural, 307
subdural, 241, 307,324, 344
Hematopoiesis, extramedullary, 132
Hemochromatosis, 26, 28, 91, 92,
94,143,171,186,189
Hemoglobin e disease, 114, 117,
120,121
Hemoglobinopathies, 1 II, 116,117,
118,119,130
Hemoglobin se disease, 120, 121,
462
Hemoglobin S-thalassemia disease,
121
Hemoglobinuria, paroxysmal
nocturnal, 1/5,123, 124,128,
135
Hemolysis, 270
delayed transfusion-related, 112
intramedullaJy, III
Hemolytic anemias, 115, 123,132
acute, 485
autoimmune, Ill, 112,114,436
drug-induced, 112
microangiopathic, 108, 109, 110,
112
nonspherocytic, I I I
Hemolytic-uremic syndrome, 109,
IlO,411
Hemophilias, 141, 142
Hemorrhage, 266
eNS, 346
diffuse alveolar, 37
hypertensive intracerebral, 309
hypertensive intraparenchymal,
308
intracranial, 22, 442, 446
primary pulmonary, 293
subarachnoid, 305, 308, 325
Hemorrhoids, 244
Hemotympanum, 445
Henoch-Schbnlein purpura, 156, 290,
292,443
Heparin administration, 142
Hepatic abscess, 245
amebic, 98
pyogenic, 97
Hepatic disease, 362, 363
Hepatic vein obstruction, 96
Hepatic vein thrombosis, 90
Hepatitis, 83,101,126,127,211,
227,247,363,491
acute, 97,98,99,100,428
alcoholic, 90, 93
autoimmune, 91, 92
chronic, 246
drug-induced, 93
granulomatous, 213
viral, 90, 91, 92,93,481
Hepatitis A, 90, 94
Hepatitis B, 290
Hepatitis e, 91, 158, 290, 362,402
Hepatocellular carcinoma, 245
Hepatomegaly, 97, 453
Hepatopathy, nonmetastatic, 260
Hepatosplenomegaly, 171
Hepatotoxin ingestion, 481
Hernia, 414, 426
femoral, 236, 426
incarcerated, 236, 444
inguinal, 426
Herpangina, 198, 372
Herpes folliculitis, 367
Herpes gestationis, 31;7
Herpes simplex, 372. 388
Herpes simplex infection, 371,373
Herpes simplex vilUs (HSV), 85,
19~ 201,237,243,403
infection, 161
ulcers, 328
Herpes zoster, 202, 366,373, 428
Herpetic whitlow, 240
Hiatal hernia, 73
High-altitude residence, 279
Hip fracture, 453
HirschsplUng's disease, 449
Hirsutism, 188, 364
Histoplasmosis, 55, 58, 240
Hives, 389
HIV infection, 53, 80,126,127,138,
139, 161, 170, 285, 363, 365,
372,373,375,380,390
acute, 201, 211
complications of, 343
Hodgkin's disease, 138,139,355
Homocystinuria, 454, 455
Hordeolum, 469
Hormone deficiencies, 347
Hormones, exogenous, 400
Huntington's disease, 313
Hydatidiform mole, 255
Hydrocele, 258, 426
Index 511
Hydrocephalus, normal pressure,
312,323,324
Hydrogen sulfide poisoning, 490, 495
Hydronephrosis, 437
Hydrophobia, 71
Hyperaldosteronism, 34, 190, 271,
277, 281
Hyperandrogenism, 364
Hypercalcemia, 183,272,272, 275,
324,325,326
Hypercapnia, 104
Hypercoagulability,454
Hypercortisolism, 187
Hyperglycemia, 196, 269, 275
Hyperkalemia, 270, 299,484
Hyperlipidemia, 468
Hypermagnesemia, 175
Hypernatremia, 268
Hypernephroma, renal cell, 260
Hyperosmolality,280
Hyperosmotic nonketotic diabetic
coma, 196
Hyperparathyroidism, 136, 143,183,
185,272,275,277,449
Hyperphosphatemia, 273, 274
Hyperpigmentation
drug-induced, 395
postinflammatory,395
residual, 360
Hyperplasia, endometrial, 252
Hyperprolactinemia, 176
Hypersensitivity pneumonitis, 62
Hypersensitivity reaction, to
carbamazepine,211
Hypersensitivity vasculitis, 153,155,
156
Hypersplenism, 123, 124, 127
Hypertension, 34, 298, 347
benign intracranial, 311
chronic, 411
essential, 3, 190,191
malignant, 109, 11 0
Hypertension, pulmonary, 7
with Graham Steel! murmur, 10
primary, 2, 4, 6, 57
with right heart failure, II
Hypertensive crisis, 467
Hypertensive heart disease, 27, 28
Hypertensive retinopathy, 462, 467,
595
Hyperthyroidism, 80,151,180, 183,
255,271,275,277,324,329,
333,334,343,362,409,485
Hypertrophic obstructive cardiomyopathy
(HOeM), 27, 28
Hyperuricemia, 295
Hypervolemia, 277
Hypoalbuminemia, 182
Hypoaldosteronism, 270
Hypocalcemia, 220, 273, 277
Hypoglycemia, 192, 196,241,306,
307,344,346,483,492,494,
496
Hypoglyconhachia, 206, 241
Hypogonadism, rrulle, 189
Hypokalemia, 271,299,447
Hypomagnesemia, 182, 273, 275, 277
Hyponatremia, 104,269, 325,451
Hypoparathyroidism, 182, 273,274,
371
Hypophosphatemia, 274, 275
Hypophosphatemic disorders, 184
Hypopigrnentation,
postinflammatory,394
Hypotension
orthosatic, 271
postural, 330
Hypothalamic disease, 176
Hypothermia
exposure, 179
neuroglycopenic hypoglycemia,
192
Hypothyroidism, 24, 63,169,174,
176, 179, 180, 182,269,291,
312,324,342,362,392,409,
449,485
Hypovolemia, 269
Hypoxemia, 278, 325
Hypoxia, 104, 130, 192,279, 344,
346,495,496
Hysteria, 306
I
Idiopathic thrombocytopenic purpura
(ITP), 128, 140, 225
IgA deficiency, I 13
IgA nephropathy, 292, 302
Ileal loop constriction, 299
Ileocecal disease, 77
Ileus
adynamic, 421, 422
paralytic, 422
Impetigo, 349, 350, 351, 352, 368,
372, 377
Incontinence, urinary, 323, 417
512 Index
+
Infarctions
mesenteric, 86
renal, 260, 284
small-vessel,315
Infections, 186, 325, 343, 399
bacterial, 198, 374, 435
cervical, 251
chronic, 131, 147, 154
eNS, 344, 346
corneal. 456, 458, 460
gas-forming, 219
in rheumatoid arthritis, J46
Infectious mononucleosis, 128, 134,
138,201,211,214,233,436,
441
InAuenza, 207, 208, 210
Insect bites, 363, 378, 389, 398
Insomnia, 332
Insulin resistance syndromes, 194
Intercostal neuropathy, 13
Interferon, 342
Interstitial lung disease, 43
InteJtrigo, 371
Intestinal ischemia, 427
Intoxication, 344
Intracranial hemorrhage, 22, 442, 446
Intracranial mass, 442
Intracranial tumors, 265
Intrauterine device, 401
Intussusception, 444
Iron deficiency anemia, 67, 106, 107,
114, lIS, 117, 118, 122, 123,
131,244,377,392,492
Iron toxicity, 326, 494, 498
Irritable bowel syndrome, 76, 79, 82,
87,262,414
Ischemia
in infants, 495
mesenteric, 427
Ischemic cardiac disease, 27,28,57,73
Ischemic colitis, 82
Isoniazid (INH) toxicity, 49/,494
Isopropanol toxicity, 494
J
Jaundice, 90, 91,97,100
Jejunal diverticulosis, 78
Jodbasedow phenomenon, 178
Junctional rhythm, 270
Juvenile rheumatoid arthritis, 29,
436,438, 441,443
Juvenile spondyloarthropathy, 164
K
Kallman's syndrome, 189
Kaposi's sarcoma, 259, 380, 385
Kawasaki disease, 211, 435, 441,443
Keratitis, 198,365
Keratoacanthoma, 384
Keratosis
actinic, 375, 381, 382, 383,384
seborrheic, 375, 376, 381, 382,
383,385
solar, 382
stucco, 381
Ketoacidosis, 280
alcoholic, 195
diabetic, 195
Key-Hodgkin murmur, 10
Kidney
adenocarcinoma of, 260
myeloma, 295, 297
pelvic, 254
single,296
Kikuchi's disease, 238
Kyphoscoliosis, thoracic, 316
L
Lactase deficiency, 79
Lactation, 176
Lactic acidosis, 195, 280, 490, 494
Lacunar infarcts of subthalamic
nuclei, 313
Lamben-Eaton syndrome, 320
Laryngeal nerve palsy, 243
Laryngitis, chronic, 243
Laryngomalacia, 431,434
Laryngospasm, 46
Larynx, foreign body in, 431,477
Laxatives, 190,274
Lead intoxication, 106, 144,449
Lead poisoning, 4Y2
Learning disability, 492
Left atrial enlargement, 68, 69
Left atrial myxoma, 7
Left hean syndrome, 440
Left ventricular failure, 2, 4, 7, 10,
3!,33
Legionnaire's disease, 226
Leg ulcers from venous
insufficiency, 399
Leiomyoma, uterine, 254,404, 414
Leiomyosarcoma, 262, 404
Lenegre's syndrome, 23
Lentigo
simplex, 386
Index 513
solar, 381, 385, 386
Leprosy, 242, 356,370,390,394
Leptospirosis, 90
Leukemia, 147,438,443,460
acute, 123, 124, 126, 127,128,
135,140,211,224
acute lymphoblastic, 436
acute monocytic, 85
acute myeloblastic, 133
chronic lymphocytic, 134, 135,
137,140
chronic myelocytic, 132
chronic myelogenous, /29
hairy cell, 132, 134,135
malignant epithelioma, 85
retinopathy of, 462
Leukemias, 362
Leukemoid reactions, 129
Leukoagglutination reaction, 113
Leukocytosis, 227, 270
Leukoderma, 394
Leukoplakia, 357, 371
Lev's syndrome, 23
Lewy body disease, diffuse, 312
Lice
body, 377
head, 351, 377
pubic, 377,403
Lichen planopilaris, 393
Lichen planus, 357, 360, 369, 371,
374,376,388,390
cutaneous, 363
Lichen sclerosis, 394, 403
Lichen sclerosus, 357
Lichen simplex chronicus, 363
Licorice ingestion, 190,271,281
Liddle's syndrome, 271
Light eruption
polymorphous, 39, 359, 365
Lipohyalinosis,429
Lipoma, of spermatic cord, 426
Lithium toxicity, 484, 493
Li vedo reticularis, 160
Liver disease and disorders. See also
Hepatitis
alcohol ic, 481
anemia of, 117
cholestatic, 95
chronic, 103
granulomatous, 96
metabolic, 91
metastatic, 96
severe, 108
Liver failure, 104,362
Laffter's syndrome, 47
Loose anagen syndrome, 393
Low back pain, 414
Ludwig's angina, 46
Lung
abscess, 48, 50, 52, 53,66,71,240,
263
cancer of, 239
Lung disease, restlicti ve, 279. See
also Chronic obstructive
pu Imonary disease
Lupus erythematosus, 242, 359, 365,
366, 394. See also Systemic
lupus erythematosus
discoid, 357, 382, 391, 393
subacute, 390
subacute cutaneous, 368
Lupus nephritis, 302
Lupus panniculitis, 397
Lupus vulgaris, 391
Lyme bOITeliosis, 389
Lyme disease, 23, 29, 146, 147, 167,
390,438
Lymphadenitis, 139, 234, 236, 2Jl;
Lymphadenopathy, 256, 453
Lymphadenopathy, inguinal, 236, 426
Lymphangitis, 240
Lymphatic obstruction, 35
Lymphatic tear, 103
Lymph node syndrome, mucocutaneous,
441
Lymphogranuloma venereum, 234,
251,372
Lymphoma, 36, 55, 62, 77,132,137,
147,148,201,211,227,232,
233,238,240,262,460
angiocentric T cell, 157
cutaneous, 363, 380
cutaneous T cell, 354, 355, 356,
394
Hodgkin's, 128
intestinal, 78, 80, 81
in leukemic stage, 134
mantle cell, 134
with mediastinal adenopathy, 222
with monoclonal spike, 136
non-Hodgkin's, 128,135,138,139
primary cerebral, 265
Lymphomatoid granulomatosis, 157
Lymphoproliferative disorders, 157,
375
Lysosomal storage disease, 463
514 Index
+
M
Macular degeneration, age-related,
466
Magnesium
depletion of, 271
excessive intake of, 276
Malabsorption, 45, 75, 87, 149,273,
275,277,329
Malabsorptive disorders, chronic
mucosal,79
Malaria, 207, 232
Malignancy, 186,329,362,436.
See also Metastatic disease
to bone, 453
cutaneous, 393
of esophagus, 420
hypercalcemia of, 183,272
Iymphoreticular, 356
metastatic, 393
metastatic hepatic, 246
primary pulmonary parenchymal,
264
visceral, 355, 427
Malignant melanoma, 385, 460
Malignant neuroleptic syndrome, 220
Malingering, 338, 339
Mallory-Weiss syndrome, 70, 102
Malnutrition, 174,277
Mammary dysplasia, 248, 412
Manganese poisoning, 312
Mania, 180,332,342,345
Marfan's syndrome, 454, 455
Mass. See also Tumor
abdominal,298
adnexal,404
intracranial, 3 18
neck, 256
ovarian, 254, 404
Mastitis, 248
Mastitis, puerperal, 413
Measles, 199, 212,435,441
Meckel's diverticulitis, 423
Medication side effects, 325, 331.
See also specific medications
Mediterranean fever, 451
Medulloblastoma, 265
Megacolon, toxic, 89
Meibomianitis, 639
Melanoma, 380, 381, 383, 386
Melanoma, malignant, 385, 460
Melasma, 395
Meniere's syndrome, 327, 473
Meningioma, 265
Meningitides, aseptic, 205, 206
Meningitis, 210, 216, 225, 234, 308.
309,446,492,493
bacterial, 204, 206, 225, 234, 442
basilar, 31 I
benign, 318
carcinomatous, 241
chronic, 241 , 3 I I
granulomatous, 206
infectious, 220
lymphocytic, 241
meningococcal,225
tuberculous, 241
Meningococcemia, 156, 167,212,
214,233,235,443
Meningococcus, 442
Meningoencephalitis, 201
Menopausal syndrome, 409
Menorrhagia, 408
Menses, irregular, 364,408
Mental retardation, 454
Mental status changes, 194, 278, 330
Mercury, 485, 492
Mesenteric adenitis, 77, 423
Mesenteric infarction, 86
Mesenteric ischemia, 427
Mesothelioma, pleural, 59, 264
Metabol ic disorders, 324
Metabolic storage disease, 463
Metastatic disease, 41, 105, 136, 138,
184
to bone marrow, 128, J3J
from extrapulmonary primary
tumor, 263
Methanol poisoning, 494
Methemoglobinemia, 495
Methylphenidate, 343
Metoclopramide toxicity, 312
Microangiopathy, 399
Migraine headache, JU5, 3U7, 311,
463,474
Miliaria, 364, 367
Milk-alkali syndrome, 183,272
Mineralocorticoids, 3, 271
Mitral regurgitation,S, 6, 8, 9, 12,
455
Mitral stenosis, 7, 10, I I, 36, 57
MitraJ valve prolapse, 7
Mittelschmerz, 423
Mobitz I atrioventricular block, 23
Mobitz ]] atrioventricular block, 23
Moles, 385
Molluscum contagiosum, 374, 375,
386
-$-
Index 515
Mondor's disease, 248
Mononeuritis multiplex, 173
Mood disorders, 344
Morphea, 149,394
Mouth breathing, 266
Mucocutaneous lymph node
syndrome, 441
Multiple myeloma, 136. 137,143,
154,158,166,168,172,183,
184.185,274,418
Multiple sclerosis, 173,307,315,
316,319,473
Multiple system atrophy, 312
Mumps, 203,480
Munchausen syndrome, 447
Muscular dystrophy, 151
Myalgia syndrome, eosinophilia,
169
Myasthenia gravis, 151. 221,223,
320,321
Mycobacterial infections, 40, 53, 240
Mycobacterium al'ium·intracellulare
infection, 81
Mycobacterium leprae, 242
Mycoba<:teriwn tuberculosis, 241
Mycoplasma pneulIlonia.e infection,
361
Mycoses, pulmonary, 52, 263
Mycosis fungoides, cutaneous, 356
Myelitis, transverse, 132,316,317,
319
Myelodysplastic syndromes, J06,
107,115.123,124,125,126,
133,140
Myelofibrosis, 127, 132, 132. 135
Myeloma, 362. See also Multiple
myeloma
Myeloma kidney, 297. See also
Multiple myeloma
Myelopathy, transverse, 309
Myeloproliferative disorders, 96,
129, 130, 131,132
Myoblastoma, granular cell, 253
Myocardial infarction, 14, 15,16,39,
50,56,71,99,113,172,216,
226,333,427,428
acute, 1, 17,23,30
in sudden cardiac death. 22
Myocardial ischemia, 65, 488
Myocarditis, 23, 25. 26, 223
Myofascial pain, 414
Myoma
atrial, 36
prolapsed uterine, 408
uterine, 400, 40 I, 404
Myopathies, 205
drug-induced,15'1
endocri ne, 151
mitochondrial, 151
primary, 320
Myorhythmia, oculomasticatory, 80
Myositis, 151
Mylingitis, bullous, 472
Myxedema, 154, 175,179,243,
278
N
Narcolepsy, 63, 306
Nasolacrimal duct obstruction, 456
Nasopharyngeal tumor, 471
Nasotracheal intubation, 445
Neck
carcinoma of, 243
masses of, 256
pyogenic infections of, 181
tumor of, 41 I
Necrobiosis lipoidica, 390
Neisseria gonorrhoeae, 235
Neisseria meningitidis. 225
Neoplasms, 154, 204, 342, 399
cervical, 407, 408
eNS, 315, 343
conjunctival intraepithelial, 468
gestational trophoblastic, 255,
408,410
metastatic, 168, 171
pelvic, 414
uterine, 409
vaginal,407
vul var, 403
Nephritis
interstitial, 259, 282, 296, 297
lupus, 302
tubulointerstitial, 294
Nephritis syndrome, 171
Nephroblastoma,437
Nephrolithiasis, 86, 295, 300, 421,
422,421
Nephropathies
diabetic, 304
drug-induced, 297, 301
IgA, 290, 292, 302
obsl!1Jctive, 296, 297
salt-wasting, 186
uric acid, 295
516 Index
+
Nephrosclerosis
benign, 303
hypertensive, 295, 30.1
Nephrosis, 24
Nephrotic syndrome, 269, 29/, 297,
302,304
Nerve entrapment, 414
Neuralgia
postherpetic, 322
trigeminal,322
Neuritis, optic, 3 J1,315
Neuroblastoma, 437
Neurocutaneous dyspJasias, 450
Neurofibromatosis, 450
Neuroleptic malignant syndrome,
483,493
Neurologic disorders, 278
Neurologic syndrome, 335
Neuronitis, vestibular, 473, 474
Neuropathic pain, 430
Neuropathies, 242
diabetic, 399
optic, 459
peripheral, 485
Neuropsychiatric diseases, 362
Neurosis, 180
Neurosyphilis, 307, 310, 311,315,
316,343
Neutrophilic dermatosis, 360
Nevi, 375, 381, 383, 385, 386
Becker's, 386
bl ue, 380, 386
epidermal, 386, 396
pregnancy-associated darkening
of,385
Nevoid basal cell carcinoma
syndrome, 383
Niacin, 193, 194
Nicotine, addiction to, 160
Nipple stimulation, chronic, 176
Nocardiosis, 239, 240
Nonketotic hyperosmolar coma, '193,
194,266
Nonsteroidal antiinflammatory drugs
(NSAIDs), 329
Nummular dennatitis, 368
Nummular eczema, 350. 354
o
Obesity, severe, 187
Obsessive-compulsive disorder, 334,
337, 348
Obstruction, functional, 422, See
also Pseudo-obstruction
Ochronosis, 395, 452
Ocular ischemic syndrome, 462, 595
Ogilvie's syndrome, 89,422
Oligemia, pulmonary, 440
Onychomycosis, 354, 369
Ophthalmic artery occlusion, 463
Opioid dependence, 346
Opioid poisoning, 346, 496
Opioids, 326, 344
Optic nerve, congenital
abnormalities of, 459
Oral contraceptive use, 3, 34
Orchitis, 258, 285, 286
Organic disease, 338. 339
Organophosphate exposure. 496
Organophosphate insecticide
poisoning. 489
Osteitis deformans, /85
Osteitis fibrosa cystica. 185
Osteoarthritis, 143. 146,452
Osteogenesis impelfecta, 184
Osteomalacia, 184,273,275
Osteomyelitis. 29. 119, 168,218.
232,328,366,438
Osteoporosis, 162, 172, 184, 184
Otalgia, 472
Otitis
acute external, 472
external, 445, 478
malignant, 478
Otitis media, 327,439,445
acute, 471. 472
serous, 243,471, 472
Otosclerosis, 327
Ototoxicity, 327
Ovarian torsion, 406
Ovary
benign masses of, 254
cysts of, 424
mass of, 404
tumors of, 254
Overdose, drug, 481. See also
specific drug
Overlap syndromes, 149,150
Ovulation. 403
p
Paget's disease, 185. 272,383
Pain, 325
abdominal-pelvic. 406, 451
Index 517
chronic pelvic, 405, 414
neuropathic, 430
radicular, 99
Pai n syndromes, 294
Palsy, progressive supranuclear, 312
Pancreas
ascites of, 103
carcinoma of, 87, 90, 101, 247,
425
malignancy of, 73
pseudocystof,425
tumor of, 231
Pancreatic insufficiency, 45, 78, 79
Pancreatitis, 71,74,75, 82, 86, 86,
87,99, 100, 182,397,418,422,
425,427,428,444
Pancytopenia, 115, 123
Panhypopituitarism, 174
Panic attacks, 191, 306, 332
Panic disorder, 333, 336
Panniculitis, poststeroid, 397
Pannus, 468
Papilledema, 462
Papilloma, intraductal, 412
Papillomatosis, 396
Parachute mitral valve, 36
Paraldehyde, 494
Paralysis, 271
familial periodic, 317
periodic, 190
Paralysis syndromes, 32/
Parasites, intestinal, 362
Parasitosis, delusions of, 362
Parkinson's disease, 179,3/2,323,
324, 342,493
Paronychia, 369, 371
Parotid gland, tumors of, 152
Parotitis, 480
Parotitis, epidemic, 203
Parovirus B19 infection, 125
Paroxysmal supraventricular
tachycardia (PSYT), 20
Patent ductus aI1eliosus, 6
Pediculosis, 377
Pediculosis capitis, 35 I
Pediculosis corporis, 378
Pellagra, 359
Pelvic adhesions, 414
Pelvic inflammatory disease (PID),
235,239,254,300,401,402,
40~ 410,414,423,424,448
Pelvic organ prolapse, 407
Pelvic pain, chronic, 405, 414
Pemphigoid
bullous, 357, 360, 361,379,387,
388,389
cicauicial, 387, 388
Pemphigus, 371, 372
foliaceus, 388
paraneoplastic,388
vulgaris, 357, 361,379,388
Penis
erosions of, 360
pearly papules of, 376
Peptic ulcer disease, 13,14,15,64,
70,73,75,76, 82, 99,102,244,
329,418,423,428,451
Pericardial disease, 24
Pericardial effusion, 68, 69
Pericarditis, 14, 15, 16,39,71
acute, 1,30
consuictive, 28, 31,32, 94,96,291
uremic, 30
Pericholangitis, 83
Perioral dermatitis, 365
Peripheral vascular disease (PYD),
347, See a/so Diabetes
Peritonitis, 103,406
Personality changes, 340
Personality disorders, 334, 337,340,
342,343
Pertussis, 88,128,134,224,434,436
Peutz-Jeghers syndrome, 444
Pharyngitis, 211,223
bactelial,479
streptococcal, 214, 441
viral,214
Pharyngoesophageal diverticulum,
4/1
Phenothiazine overdose, 496
Phenothiazine toxicity, 312
Phenotypic abnormalities, 433
Pheochromocytoma, 3, 34,180,191,
192, 193,194, 333, 334, 409,
486
Phlegmon, pancreatic, 425
Phobic disorders, 336
Phosphate intake, excess, 274
Phosphorus poisoning, inorganic, 221
Photodermatitis, contact, 395
Photosensitive drug eruption, 358
Photosensitivity disorders, 359
Picas, 106
Pick's disease, 324
Piebaldism, 394
Pingueculum, 468
518 Index
+
Pituitary tumor, 189
Pityriasis alba, 370, 394
Pityriasis rosea, 351,353, 354,357,
368,370,378
Pityriasis rubra pilaris, 354, 355
Pityriasis versicolor, 370
Plague, 222, 233, 234
Platelet disorders, 141
Pleura, inflammatory conditions of,
264
Pleural effusion, 38, 56
Pleural thickening, 38
PleurOdynia, 226
Pneumococcal infections, 2/6
Pneumoconioses, 53, 54, 55, 58, 59
Pneumonia, 13, 14, 15, 16,25,30,
48,49,56,199,216. See aLso
bronchiolitis obliteransorganizing
pneumonia
acute, 60
acute bacterial, 50, 51, 53, 234
acute infectious, 61
anaerobic, 52
atypical, 51,62,201,213,226
cavitary bacterial, 52
chronic eosinophilic, 61, 155
with empyema, 39
infectious, 226
interstitial,54
lower lobe, 300, 422
primary, 37, 210
right lower lobe, 97, 98, 99, 423,
428
with septic shock, 31
severe, 40
staphylococcal, 210
viral, 50, 224
Pneumonitis
chlamydial,434
hypersensitivity, 51,54,62
inhalation, 49
lymphocytic interstitial, 55
Pneumothorax, I, 13, 14, 15, 16,30,
56
catamenial, 39
spontaneous, 39
tension, 22, 31
Poisoning
food, 229, 230
heavy metal, 317
sympathomimetic, 498
Poisons, 280. See also specif7.C
poisolls
Poliomyelitis, 205,221,317
Poliomyelitis, bulbar, 320
Polyarteritis, microscopic, 157,302
PolyaI1el;tis nodosa, f53,155, '156,
157,292,293,427
Polycystic kidney disease, 260, 298,
437
Polycythemia vera, f 30, 362
Polydipsia
primary, 269
psychogenic, 177
Polymyalgia rheumatica, 146, 151,
f 54, 170, 342
Polymyositis, 150, /5/, 172,320
Polyneuropathies, 3 J9,320,321,451
acute infiammatOly, 317
postinfectious,205
Polypharmacy, 330, 33/
Polyps
adenomatous, 84
benign colonic, 244
of colon and rectum, 84
endometrial, 252
uterine, 400
Porphyria cutanea tarda, 359
Porphyrias, 191,317,451,492
Postel;or vitreous separation, 464
Postictal state, J04, 307, 493, 496
Postnasal drip, 43
Post-transfusion state, 122
Posttraumatic stress disorder
(PTSD), 333, 336, 342
Potassium levels, 321
Potassium restriction, 271
Preeclampsia-eclampsia, 109, 110,
191,411
Pregnancy, 176,269,279,363,400,
404,409,416
ectopic, 252, 255, 400, 406, 408,
4/0,423,424,451
hyperemesis of, 70
intrauterine, 4'10
multiple, 255
tubal,254
Premature atrial contractions (PACs),
17,19
Presbycusis, 327
Pressu re sores, 328
Presyncope, 330
Prinzmetal's angina, 14
Proctitis, 198
Prodromal pain, 373
Prolactin-stimulating drugs, 176
Index 519
Propranolol, 484
Prostate, cancer of, 257, 287
Prostatism, 284
Prostatitis, 283, 283, 285, 300
Prostatodynia, 283
Prurigo nodularis, 363, 363, 380
Pruritus
anogenital,377
di ffuse, 362
Pseudoacromegaly, 175
Pseudocyst, of pancreas, 418, 425
Pseudodementia, 327
Pseudofolliculitis, 364, 367
Pseudogout,I44, /45,146,172
Pseudohyperaldosteronism, 190
Pseudohyperkalemia, 129
Pseudohypoglycemia, 129
Pseudohyponatremia, 269
Pseudohypoparathyroidism, 182
Pseudolymphoma, 138,139
Pseudomembranous colitis, 83
Pseudo-obstruction
colonic, 422
intestinal, 89,421
Pseudotumor, 41
Pseudolllmor cerebri, 311
Psoriasis, 350, 351, 353, 354, 356,
357,360,363,368,369,376,
383
erythrodermic, 355
inverse, 371
Psoriatic arthritis, 147, 162,163,
164,165
Psychiatric disorders, 241, 324, 325,
329,344,473
Psychoneurosis, 65, 192
Psychoses, 332, 451, 482
Psychosomatic disorders, 338
Psychotic disorders, 335, 336, 337,
340
Psychotropic drug intoxication, 493
Pterygium, 468
Pulmonary alveolar proteinosis, 60
Pulmonary atresia, 440
Pulmonary edema, 56
Pulmonary edema, cardiogenic, 37
Pulmonary emboli, 1, 13, 14, 15, 16,
22,30,39,42,50,51,56,71,
120,216,226,279
chronic, 2, 4, 6, 57
recurrent, 44
Pulmonary fibrosis, 40, 51,54, 55,
58,59,61,62
Pulmonary hypertension, 7
with Graham Steel! murmur, 10
primary, 2, 4, 6, 57
with right heart failure,11
Pulmonary infection, 42
Pulmonary nodule, 41
Pulmonary stenosis, 2, 4, 12,33
Pulmonary vasculitis, 52
Pulmonary venous return,
anomalous, 440
Pulseless disease, 159, See also
Takayasu's arteritis
Pulsus paradoxus, 31
Purpura, palpable, 443
Pyelonephritis, 113, 284, 300, 423
Pyloric stenosis, 432
Pylorospasm, 432
Pyoderma gangrenosum, 328, 398,
399
Pyogenic upper airway process, 46
fever, 90, 213,227,232
(J wave intarction, 441
R
Rabies, 209, 220
Radiation colitis, 83
Radicular pain, 99
Radiculopathy, cervical, 315
Radiographic artifact, 84
Rash
of bullous drug reactions, 361
heat, 367
petechial,225
of roseola infantum, 435
ofSLE,148
Raynaud's disease, 149, 160
Recklinghausen's disease, 450
Rectal prolapse, 407
Rectal sphincter tone, 417
Rectum
carcinoma of, 244, 424
polyps of, 84
Reflex sympathetic dystrophy, 172,
430
Reflux disease, 13, 14, 15, 16
Renal artery stenosis, 3, 34, 303
Renal colic, 418, 427
Renal disease
atherosclerotic, 303
520 Index
Renal disease (continued)
chronic, 411
cystic, 130
end-stage, 303, 304
Renal failure, 176, 183,269,273,
274,295,296,329,363
acute, 288, 289
chronic, 182, 298
with oliguria, 270
Renal infarction, 260, 284, 404
Renal insufficiency, 34, 270, 276,
289,496
Renal parenchymal disease, 3
Renal stone, 119
Renal tubular acidosis, 271
Renovascular disease, 190
Reserpine, 342
Respiratory syncytial virus (RSY)
disease, 434
Reticulocytosis, 122, 123
Retinal artery occlusion, 463
Retinal detachment, 460, 464
Retinal disorders, bilateral, 459
Retinal vein occlusion, 462,467,595
Retinitis pigmentosa, 459, 460
Retinoblastoma, 460
Retinopathy
diabetic, 462, 465, 467
hypertensive, 462, 467, 595
radiation, 462, 467, 595
sickle cell, 467, 595
talc, 467, 595
Retinoschisis, 459, 464
Reye's syndrome, 204
Rhabdomyolysis, 151,210,274
Rheumatic fever, 29, I 19, 168,438,
441
Rheumatic heart disease, 11, 452
Rheumatoid arthritis, 29, 80, 143,
144,145,146, 148,150, 152,
154,158, 162, 163, 164, 165,
166,170, 172
Rheumatoid nodules, 390
Rhinitis
allergic, 475, 476,479
viral, 475, 479
Rickettsial infections, 212, 218, 227,
233,234
Right heart failure, 12
Right ventricular hypertrophy, 440
Right ventricular infarction, 31,32
Rigors, in pneumonia, 216
Ringworm, 368
Rocky Mountain spotted fever, 212,
218,443
Rosacea, 365,365, 391
Roseola infantum, 435
Rubella, 200,201,211,435
Rubeola, 199
Rule of tens, 191
Rule of thirds, 25
Rule of threes, 439
Ruptured viscus, 71
S
Salicylate poisoning, 279, 491, 497
Salicylates,494
Salivary glands, tumor of, 480
SaJmonella gastroenteritis, 228
Salmonella infection, 229
Salmonellosis, 230, 231
Salpingitis, 406
Salt intoxication, 268
SAPHO syndrome, 162
Sarcoidosis, 26, 39, 43, 53, 54, 55,
5R, 59, 62, 95, 13R, 139, 147,
152,158,167,171,183,203,
222,241,242,272,318,390,
467,595
Sarcoma
Ewing's, 168
Kaposi's, 259, 380, 385
osteogenic, 185
Scabies, 349, 352, 362, 369, 377,
378,403
Scalp
dissecting cellulitis of, 367
lichen planopilaris of, 39
Scarlet fever, 218, 358, 366, 435
Schatzki's ri ng, 68
Schistosomiasis, 94, 102
Scleritis, 456, 460
Scleroderma, 149, 172, 242
of esophagus, 66
overlap syndromes with, 149
Sclerosis
posterolateral, 319
systemic, 148,149, 150,152,169
Scrapings, "spaghetti and meatballs,"
370
Scrofula, 239
Seborrheic dermatitis, 349, 351, 352,
353,354,355,365,368,370,
371,377,391
Index 521
+
Seborrheic keratosis, 375, 376, 381,
382,383,385
Sedative abuse, 63
Sedative-hypnotics
dependence on, 344
overdose, 346, 496
withdrawal from, 345
Seizure disorder, 63, 345, 411
Seizures, 306, 307, 309, 491
complex partial. 343
in COPD, 498
febrile, 446
focal,314
Selective serotonin reuptake
inhibitors (SSRls), 329, 347
Sepsis. 195.266,279,442.491
central nervous system, 104
early, 56
gram-negative, 218
Septicemia, gram-negative, 216
Septic shock, 100,485
Sequoiosis, 62
Serotonin syndrome, 483
Serous otitis merna, 243, 471, 472
Sexual abuse, 414
Sexual dysfunctions, 347
Sexually transmitted diseases (STDs),
198,251,253
Sezary syndrome, 355
Sheehan's syndrome, 174
Shigella dysentery, 228
Shigellosis, 229. 230
Shingles, 202,373
Shock. 71. 267
hypotensive, 487
septic, 100, 485
severe hypertension in, I
Sialadenitis, acute, 480
Sialolithiasis, 203
Sicca complex, 150, 152
Sickle cell anemia, 119, 120, 121,399
crisis of, 492
retinopathy of, 595
Sickle thal~ssemia, 120
Sideroblastic anemia, 106, 107, I I I,
117, 118,122, 133
Silicosis, 58, 59
Sinus, carcinoma of, 475
Sinus arrhythmia, 17
Sinusitis, 43
acute, 475, 479
sphenoid,475
Sinus tachycardia, 18
Sister Mary Joseph's node, 247
Sjogren's syndrome, 146, 148, 150,
152.203,409,480
Skin, cancer of, 328
Skin tag, 375, 376
Sleep apnea, 2, 4, 57, 63
Small bowel obstruction, 86, 421,
432,444
Smoking, chronic irritation from, 152
Sodium. 493
Sodium loss, 266
Solar lentigo, 381, 385, 386
Somatization, 4·14
Som~toforrn disorders, 333. 334,
337,338,339
Spermatocele, 258
Spherocytosis, hereditary, 99, Ill,
114
Spinal cord
compression of, 315
tumor of, 316
Spine, cervical, arthritis of, 316
Splenomegaly, 453
Spondyloarthropathies
HLA-B27, l;0, 161
juvenile, 163, 164
seronegative, 143, 167
Spondylosis, cervical, 319
Staphylococcal infections, 50, 217,
222
Staphylococcal scalded skin
syndrome, 361
Starch ingestion. 203
Starvation, 275
Status epilepticus. 306, 325
Steroids, 342, 343
Stevens-Johnson syndrome, 198,
361,379.388
Still's disease, 147. 166,208,227.
438
Stimulant overdose, 482
Stomach
c~rcinoma of, 262
malignancy of, 73
Stomatitis, aphthous, 388
Streptococcal infections. 215,217,
218,222
Stress, 332
Stress disorders, 335
Stroke, 306,342,344,346,429,463
carotid distribution. 318
hemorrhagic, 307
ischemic, 307
522 Index
Strongyloidiasis, 42, 61
Strychnine poisoning, 220
Subdiaphragmatic process, 38
Submandibular gland, adenitis of,
480
Substance abuse, 333, 334, 335, 340,
342,347
Substance intoxication, 337, 343,
345
Sudden death
in athletes, 27
cardiac, 22
Sulfhemoglobinemia, 495
Sweating, skin sodium loss with, 266
Sweet's syndrome, 360, 379, 398
Sydenham's chorea, 313
Sympathomimetic poisoning, 498
Syncope, 306,330
Syndrome of inappropriate antidiuretic
hormone (SIADH), 269
Synovitis, microcrystalline, 166
Synovitis-acne-pustulosishyperostosis-
osteitis (SAPHO)
syndrome, 162
Syphilis, 1911, 201, 236, 237, 242,
251,358,360,372,397,402.
403,473
rectal,85
secondary, 90, 353, 354, 357. 368.
370.376,390.392.393
tertiary, 39, 324
Syringomyelia, 173,242,315,316
Systemic lupus erythematosus
(SLE), 29,126,127,139,140,
146.147, /48,150,152,161,
170,292,293,302,315,438
T
Tabes dorsalis, 319
Tachycardia
atrial,20
atrioventricular nodal reentry, 18
automatic atrial, 18
multifocal atlial, 17, 18,19
paroxysmal supraventricular, 20
permanent junctional
reciprocating, 20
reentry, 19,20
in rheumatic fever, 29
in typhoid fever, 227
with variable block, 17
ventricular, 21
Takayasu's arteritis, 154, 157,159,
429
Tamoxifen therapy, 404
Tardive dyskinesia, 313, 493
T cell lymphoma, cutaneous, 354,
355,356,394
Telogen effluvium, 392
Temporomandibular joint (TMJ)
dysfunction, 322
Testes
trauma to, 285, 286
tumors of, 258, 285,286
Testicular torsion, 285, 286, 423,426
Tetanus, 209, 220
Tetralogy of FaJlol, 440
Thalassemia, 106. 122, 399
beta, 120
major, 116
sickle, 120
Thallium, 485
Theophylline overdose, 498
Thiamin deficiency, 325
Third-spacing, 269
Thoracic outlet syndrome, 323
Thorax, structural disorders of. 278
Thromboangiitis obliterans. /60.292
Thrombocytopenia
heparin-induced, 108
sepsis-induced, 108
Thrombocytopenic purpura. 436, 443
Thrombocytosis, 270
essential,131
reacti ve, 131
Thromboembolism, pulmonary, 56
Thrombophlebitis, 248
Thrombosis
deep venous, 35
hepatic vein, 90
venous, 366
Thrombotic thrombocytopenic
purpura (TIP), 108,109, 110,
140,411
Thyroglossal duct cyst, 256
Thyroid
cancer of, 178, 181, 256
exogenous admi nistration, 180
Thyroiditis, 178, 181, 256
Thyroid nodules, benign, 256
Thyroid storm, 498
Thyrotoxicosis, 191
Thyroxine, 343
Tic disorder, 314, 337
Tic douloureux, 322
Index 523
Tick-borne disease, 208
Tick paralysis, 221
Tietze's syndrome, 13, 14, 15, 16
Tinea capitis, 392, 393
Tinea corporis, 350, 353, 354, 363,
368, 390
eczematous, 356
Tinea faciei, 364
Tinea unguium, 369
Tinea versicolor, 351, 353, 369,370,
394
Tobacco use, 130, 152
Tourette's syndrome, 312, 337
Toxic epidermal necrolysis, 36/, 388
Toxic shock syndrome, 214, 215,
218,358,435,441
Toxoplasmosis, 138,201,211,238
Tracheobronchitis, acute, 49
Transfusion reaction, hemolytic, I 13
Transposition of great arteries, 440
Trauma, 399, 446
head, 196, 491
testicular, 285, 286
uterine, 400
Tremor, essential, 312
Trichinosis, 169
Trichotillomania, 392, 393
Tricuspid atresia, 440
Tricuspid regurgitation, 8, 12
Tricuspid stenosis, 7, 10, 11
Tricyclic antidepressant overdose,
484
Tricyclic antidepressants, 489, 492
Tricyclic antidepressant toxicity,
486,487
Trigeminal neuralgia, 322
Tropical sprue, 78, 80
Truncus arteriosus, 440
Tuberculosis, 38,40,48,52,55,58,
85,103,139,222,227,232,
238,240,263,272
clltaneous, 242, 391
genitourinary, 258, 282
intestinal, 77, 78, 81
laryngeal, 243
miliary, 128
pulmonary, 53
renal, 259, 260, 284
scarring secondary to, 257
subclinical, 397
Tuberculous meningitis, 241
Tuberous sclerosis, 394
Tularemia, 232, 233, 234
Tumors. See also Neoplasms
abdominal, 437
adrenal, 281
benign, 245, 253,263
of bile ducts, 246
bladder, 287
bone, 438
brain, 307, 310,311,429
of breast, 197,248,249,413
epidural, 319
esophageal, 65, 66, 67, 68, 69, 72,
261,411
gastric, 262
of genitOUlinary system, 284
of head, 305
intracranial, 265, 308,309,446,
450
intraocular, 460
intraspinal, 450
liver, 245
lung, 263
mediastinal, 65, 66, 67, 68, 69, 72,
411
metastatic, 245
nasopharyngeal, 471
neck,411
ovarian, 254
pancreatic, 231
parotid, 152, 203
pituitary, 189
posterior fossa, 473, 474
renal, 119
retroperitoneal, 254
salivary gland, 480
of spinal cord, 316
testicular, 285, 286
of testis, 258
Wilms', 437
Typhoid fever, 207,227,232,233,234
U
Ulcerations, factitious, 398
Ulcerative colitis, 77, 80, 83, 101,
229,230,246
Ulcers, 398. See also Peptic ulcer
disease
anal, 85
aphthous, 161, 198
cervical, 402
chronic nonhealing, 384
corneal, 457
decubitus, 328
524 Index
Ulcers (continued)
duodenal, 74, 86, 87
gastric, 74, 75, 76, 262
genilal,236
herpes simplex virus, 328
immunologic, 457
oral aphthous, 161
sterile, 457
venereal, 237
venous insufficiency, 328
Undifferentiated connective tissue
syndrome, 150
Upper respiratory infections, viral,
476
Uremia, 104, 195,280, 362,494
Urethral diverticulum, 417
Urethral irritation, 448
Urethral stricture, 257,287
Urethral syndrome, 414
Urethritis, 235, 282, 283, 300
Urinary retention, 287
Urinary tract. See also Genitourinary
tract
infection (UTI), 282, 417, 423,
444,447,448
tumor of, 259
Uropathy, obstructive, 289, 294
Urticruias,377,379,389
contact, 369
papular, 378
physical,389
Uterus
abnormal bleeding of, 400
anomalies of, 401
myoma of, 404
neoplasm of, 409
Uveitis, 456, 457, 458, 460
V
Vagina
infection of, 402
neoplasm of, 407
Vaginitis, 235, 403, 415
atrophic, 252, 403
chronic, 251
Vaginosis, 300
Valvular disease, left-sided, 2, 4
Variceal bleeding, 102
Varicella,202,374
Varicocele, 426
Vasculitides, 290, 292, 293, 443
Vasculitis, 148,315,398,399
Churg-Strauss, 155, 157
hypersensitivity, 153, 155, 156
nodular, 397
pathognomonic granulomatous,
157
pu Imonary, 52
systemic, 147,430
urticarial,389
Venereal diseases, 237
Veno-occlusive disease, pulmonary,
57
Venous insufficiency
leg ulcers from, 399
ulcers, 328
Venous stasis, 384, 462
Ventricular fibrillation, 16
Ventricular septal defect, 5,6,8,9,
12
Ventricular tachycardia, 9, 21
Verapamil,487
Verrucae vulgares, 375,381,384
Vertebrobasilar insufficiency, 473,
474
Vertigo, 330
Vertigo, benign positioning, 473,
474
Vesicular stone, 287
Vibrio cholerae, 121
Viral croup, 49
Viral exanthems, 358,441
Viral infections, t26, 127,202
Viral syndromes, 210
Virilizing diseases of women, 188
Viscus, perforated, 422, 444
Visual impairment, 330
Vitamin B'2 deficiency, 123, 319,324
Vitamin D deficiency, 182,273
Vitamin D toxicity, 183,272,274
Vitamin K deficiency, 108
Vitiligo, 242, 370, 394, 394
Vocal cord paralysis, 243
Volume resuscitation, 268
Volvulus, 444
Von Willebrand's disease, 141, 142,
400
Vulva, carcinoma of, 253
Vulvar dystrophies, 253, 403
W
Waldenstriim's macroglobulinemia,
135, 136, 137, 141, 158, 171
Wallet biopsy, 175
Index 525
+
Warts, 374
common, 375
genital, 376
Wegener's granulomatosis, 52, 153,
155, /5~ 290,292,293,398
Wegener's membranous
nephropathy, 302
Weight loss, involuntary, 329
secondary to medical illness, 348
Wemicke-Korsakoff syndrome, 104,
323
Whipple's disease, 78, 80
Wilms' tumor, 437
Wilson's disease, 91,92,94,312,
314
Withdrawal, 346
illcohol,345,483,492,498
drug, 498
opioid,346
substance, 333, 334, 335, 340,
342,344
X
Xanthelasma, 468
XantJlomas, 468
Xeroderma pigmentosum, 359
Xerotic dermati tis, 350
y
Yellow fever, 207
Yersinia pestis, 234
Yersiniosis,227
Z
Zenker's diverticulum, 4/1
Zollinger-Ellison syndrome, 74,75
Zoster, 202, 372,373
preeruptive,428
verrucous, 375
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