Infectious exanthems and unusual infections

Invasive disease due to group A beta-hemolytic streptococci (GABHS) can be divided into 3 categories of disease: streptococcal toxic shock syndrome (strepTSS), necrotizing fasciitis, and other invasive GABHS disease. Patients with strepTSS may have multiorgan failure within hours of presentation. Clindamycin and penicillin G should be used in combination for treatment of invasive GABHS disease. The mortality rate for menstrual staphylococcal toxic shock syndrome has decreased with early recognition and treatment, and removal of hyperabsorbent tampons from the market. Kawasaki syndrome (KS) is the most common cause of acquired heart disease in children in the U. S., and atypical forms have a higher mortality rate than typical KS. Hantavirus pulmonary syndrome is a zoonosis with an 80% mortality rate if the diagnosis is not made on first presentation and patients return to the hospital in shock. Children and adolescents with Lyme disease have an excellent prognosis and respond well to antimicrobial therapy. Cat scratch disease (CSD) is caused by Bartonella henselae and is transmitted by flea-infested kittens. CSD lymphadenopathy typically resolves spontaneously in 2?3 months; however, there is a 50% likelihood of resolution in 1 month if patients receive a 5-day treatment course with azithromycin.     

Toxic shock syndrome (TSS) in children

Toxic shock syndrome is uncommon in the prepubertal age group. Two children presented with pyrexia, macular erythroderma, vomiting, hypotension and rapid deterioration of consciousness. One child had severe neurological involvement. The diagnosis of toxic shock syndrome was established in both cases by the exclusion of other causes and by culturing staphylococcus aureus. We postulate that the neurological manifestations were caused by a direct neurotoxic action of the staphylococcal-produced toxin. Both children made a complete recovery.     

Commentary: environmental disease--a preventable epidemic.

Toxic environmental diseases are highly preventable causes of morbidity and mortality. Toxic diseases in the work environment cause an estimated 50,000 to 70,000 deaths and 350,000 new cases of illness each year in the United States; the asbestos pandemic will ultimately claim at least 300,000 lives; pediatric lead poisoning is epidemic, and an estimated 3 to 4 million US preschool children have blood lead levels above 10 micrograms/dl and could suffer long-term neuropsychological impairment. Prevention of environmental diseases can be achieved through legislation and regulation that control common-source exposures to chemical toxins. Modification of personal behaviors, such as tobacco and alcohol consumption, complements but does not replace control of toxic environmental exposures.     

Infectious disease emergencies in primary care

Infectious disease emergencies can be described as infectious processes that, if not recognized and treated immediately, can lead to significant morbidity or mortality. These emergencies can present as common or benign infections, fooling the primary care provider into using more conservative treatment strategies than are required. This review discusses the pathophysiology, history and physical findings, diagnostic criteria, and treatment strategies for the following infectious disease emergencies: acute bacterial meningitis, ehrlichiosis, Rocky Mountain spotted fever, meningococcemia, necrotizing soft tissue infections, toxic shock syndrome, food-borne illnesses, and infective endocarditis. Because most of the discussed infectious disease emergencies require hospital care, the primary care clinician must be able to judge when a referral to a specialist or a higher-level care facility is indicated.     

Toxic shock syndrome in three adolescent males

Toxic shock syndrome (TSS) is associated with a spectrum of Staphylococcus aureus infections and is not just a disease of menstruating females. We report three cases of TSS in adolescent males. In one case the origin of infection was a cauterized wart that did not appear clinically infected. Two cases were associated with bacteremia and had demonstrable acute phase antibody to toxic shock syndrome toxin-1 (TSST-1). One of these patients died. The S. aureus strain from this patient did not produce TSST-1 but did produce enterotoxin D. The historical and clinical features of TSS are reviewed.     

Lambert-eaton myasthenic syndrome: a case report and review of the literature

Lambert-Eaton myasthenic syndrome (LEMS) is a type of paraneoplastic syndrome that may initially manifest with weakness and gait abnormalities. These symptoms may precede the diagnosis of malignancy by months or years, and morbidity and mortality may be significantly affected by early detection of the malignancy. A case report and review of the diagnosis, management, and treatment of these syndromes are presented, with particular emphasis on the rehabilitation management of these patients, often overlooked in medical treatment.     

Problems and solutions in hospital-acquired bacteraemia

Despite infection control efforts, bacteraemia remains one of the most frequent and challenging hospital-acquired infections and is associated with high attributable morbidity and mortality and additional use of healthcare resources. Prevention and control of hospital-acquired blood-stream infection requires improved detection methods, better definition of patient populations at risk, more refined guidelines for the interpretation of positive blood cultures and a better discrimination between sporadic contaminants and true bacteraemia. These issues are addressed in the current review together with those related to the diagnosis, management and recent advances in the prevention of cathether-related bacteraemia, the leading cause of hospital-acquired blood-stream infection. Finally, the reasons and perspectives for blood-stream infection surveillance are briefly discussed.     

A 2012 clinical update for internists in adult nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the Western world. Associated with the metabolic syndrome, NAFLD is associated with adverse cardiovascular outcomes. A subset of NAFLD patients with histologic nonalcoholic steatohepatitis (NASH) can have increased liver related mortality. Because of the prevalence and complications of this chronic liver disease, it is important that internists understand important aspects about diagnosis and management. In this article, we aim to provide an update to clinicians related to issues surrounding prognosis, monitoring, and treatment.     

The importance of the refeeding syndrome.

In this review we discuss the refeeding syndrome. This potentially lethal condition can be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. It can be associated with significant morbidity and mortality. Clinical features are fluid-balance abnormalities, abnormal glucose metabolism, hypophosphatemia, hypomagnesemia, and hypokalemia. In addition, thiamine deficiency can occur. We describe which patient groups are more at risk for this syndrome and the clinical management of the condition.     

Intrauterine growth restriction: diagnosis and management

The diagnosis of intrauterine growth restruction often results in preterm delivery with its associated morbidity and mortality. This review aims to outline the main diagnostic and management tools available to obstetricians for the management of such pregnancies as well as the aetiological factors that might be associated with this condition.     

Toxic shock syndrome caused by pyogenic bacteria

Case reports and review of the literature. INTRODUCTION: Severe toxic shock syndrome caused by invasive infection with pyogenic bacteria Staphylococcus aureus or group A Streptococcus pyogenes, with high mortality rates in cases of the latter, remained one of the most problematic chapters of critical care medicine to date. AIMS: To give an overview on the epidemiology, clinical manifestations, the complex therapeutical approaches of the syndrome and, on the role and mechanisms of action of bacterial superantigens in the pathophysiological processes as well. METHODS AND RESULTS: Literary data, and some illustrative selected cases demonstrate that, the incidence of TSS shows increasing tendency worldwide and, that otherwise healthy, younger people are the most frequently affected. As for prognosis: early diagnosis and treatment with sufficient radicality are of decisive importance.     

Toxic epidermal necrolysis.

Toxic epidermal necrolysis is a rapidly progressive dermatologic condition associated with high mortality. Several factors have been implicated in the development of toxic epidermal necrolysis including drugs, vaccinations, infections, and neoplasia. Toxic epidermal necrolysis therapy has been compared with partial-thickness burn injury treatment. The absence of burned tissue can dampen fluid requirements and metabolic needs of toxic epidermal necrolysis in comparison to equivalent burn injury. In the following case report, a 69-year-old woman with multiple medical problems developed toxic epidermal necrolysis after treatment with metolazone and phenytoin. Her measured energy expenditure (3360 kcal) was considerably higher than previously reported caloric expenditure in toxic epidermal necrolysis patients (2500 kcal).     

Disseminated Strongyloidiasis in a Patient with Membranoproliferative Glomerulonephritis-Case Report

Strongyloides stercoralis (SS) is a unique nematode with an auto infective cycle, so that it completes its life cycle within the human host and can live there for many years. In immunocompromised patients, infection can cause Strongyloides hyperinfection syndrome (S.H.S) that is associated with serious morbidity and mortality. As various infections are one of the leading causes of membranoproliferative glomerulonephritis (MPGN), we should consider subclinical strongyloidiasis as a possible underlying disease, especially in endemic areas. Here we describe a case of strongyloidiasis following immunosuppressive therapy for MPGN, the diagnosis of which was made, only a few hours before death, by stomach biopsy.     

Refeeding syndrome with enteral nutrition in children: a case report,literature review and clinical guidelines

Refeeding syndrome is a potentially fatal complication of the nutritional management of severely malnourished patients. The syndrome almost always develops during the early stages of refeeding. It can be associated with a severe derangement in electrolyte and fluid balance, and result in significant morbidity and mortality. It is most often reported in adults receiving total parenteral nutrition (TPN), although refeeding with enteral feeds can also precipitate this syndrome.We report what we believe to be the first case of refeeding syndrome in an adolescent with newly diagnosed Crohn's disease. This developed within a few days of starting exclusive polymeric enteral nutrition. A systematic literature review revealed 27 children who developed refeeding syndrome after oral/enteral feeding. Of these, nine died as a direct result of complications of this syndrome. We discuss the implications of this syndrome on clinical practice and propose evidence-based guidelines for its management.     

Assessment of metabolic profile in a clinical setting

PURPOSE OF REVIEW: The metabolic syndrome, a clustering of abnormalities such as hyperglycemia, insulin resistance, hypertension, dyslipidemia, and central obesity, is a principal risk factor for cardiovascular disease, the leading cause of morbidity and mortality in the Western world. There are several definitions of the metabolic syndrome, all aiming at including as many persons at risk as possible. The assessment and, hence, the identification of such persons in a clinical setting is of utmost importance. RECENT FINDINGS: Clinicians should document the presence of central obesity, assessed by waist circumference measurement or determination of body composition using dual X-ray absorptiometry or measurement of visceral fat using computed tomography or magnetic resonance imaging. The presence of dyslipidemia, insulin resistance, and arterial hypertension constitutes the full profile of the metabolic syndrome. Nevertheless, elevated uric acid levels or presence of nonalcoholic fatty liver, or the diagnosis of the polycystic ovary syndrome in women of reproductive age, all are reflected in high risk of later occurrence of the full metabolic syndrome and atherosclerotic cardiovascular disease. SUMMARY: Although no unified definition for the metabolic syndrome exists, it is important to identify persons at risk, in order to reduce the resultant high morbidity and mortality rates.     

What underlies the high alcohol related mortality of the disadvantaged: high morbidity or poor survival?

STUDY OBJECTIVE: To investigate whether the large socioeconomic differences in alcohol related mortality can be explained by differences in morbidity or differences in survival. DESIGN: Register linkage study. A nationwide hospital discharge register was linked to population censuses for socioeconomic data and to the cause of death register for mortality follow up. SETTING: Finland. PARTICIPANTS: Men and women aged 15 years and older discharged from hospitals with an alcohol related diagnosis in 1991-1996. MEASUREMENTS: Mortality hazard up to the end of 1997 by socioeconomic category was estimated with Cox's regression model. MAIN RESULTS: Socioeconomic differences in alcohol related hospitalisation rates were almost as large as those that have been observed for alcohol related mortality. For example, the rate ratio among male unspecialized workers for any alcohol related hospitalisations was 3.6 as compared with upper white collar workers; among women the rate ratio was 2.7. Depending on gender, age, hospitalisation diagnosis, and cause of death, survival after discharge either showed no socioeconomic differences or it was worse among better off groups. CONCLUSIONS: The study suggests that differences in survival after hospitalisation do not cause the high socioeconomic differences in alcohol related mortality.     

A hospital discharge code review of toxic shock syndrome in Wisconsin

The Wisconsin Division of Health conducted a review of discharge coding for 142 (97%) of the state's general care hospitals for the period 1980-1983 to evaluate the use of International Classification of Diseases codes for toxic shock syndrome and to estimate completeness of reporting of recognized hospitalized cases of the syndrome to the Division of Health. Hospital use of code 040.89 (other bacterial diseases-other) recommended for toxic shock syndrome by the National Center for Health Statistics in January 1981 increased from 23% of Wisconsin hospitals in 1980 to 92% in 1983. The sensitivity of this code for toxic shock syndrome increased from 54% to 85% from 1981 to 1983; study population specificity was stable at approximately 95%, and the predictive value was 65% in 1981 and 70% in 1983. The use of codes 785.50 (shock, unspecified) and 785.59 (nontraumatic shock-other) frequently assigned to toxic shock syndrome was also assessed; all measures of their utility decreased in proportion to the increasing use of 040.89. The coding review identified 20 previously unreported cases of toxic shock syndrome; the 10 confirmed and 10 probable cases represent 4% and 21% of the state's 223 confirmed and 47 probable cases with onsets in 1980-1983. Results indicate that a National Center for Health Statistics coding recommendation for a disease of emerging significance can result in relatively uniform coding of the illness, which can provide a tool for case finding and surveillance evaluation for hospitalized cases.     

Nutrition and cardiac cachexia

PURPOSE OF REVIEW: Congestive heart failure is a leading cause of morbidity and mortality, especially in older persons. In advanced stages of the disease, congestive heart failure can be associated with serious complications such as cardiac cachexia (defined here as weight loss of more than 6% in 6 months). This review will discuss recent insights into the pathophysiology, anthropometric predictors and potential management of cardiac cachexia. RECENT FINDINGS: Cardiac cachexia and the associated progressive weight loss are sometimes overlooked by care providers. A delay in diagnosis often results in further loss of vital tissues, progressive weakness, fall-related injuries and potentially long-term care institutionalization and/or death. Emerging data suggest that congestive heart failure is a dynamic disorder of many organ systems, including the myocardial, neurohormonal, immune, vascular, gastrointestinal, renal and musculoskeletal systems. It is becoming more widely appreciated that it is the deterioration of this interactive multisystem complex that results in the systemic inflammation and progressive wasting and atrophy of muscle and other organ tissues, which is the hallmark of cardiac cachexia. SUMMARY: Cardiac cachexia in congestive heart failure patients may be associated with a low level of physical activity. A high systemic inflammatory state is another marker of cardiac cachexia. Prudent anti-inflammatory nutrition, dietary supplements and exercise can serve to ameliorate and/or potentially prevent progressive wasting. A better understanding of factors contributing to the development of cardiac cachexia will enable us to design preventive strategies and provide improved care for individuals with this debilitating condition.     

Knowledge of Toxic Shock Syndrome Among Adolescent Females: A Need for Education

Toxic shock syndrome (TSS) has been identified as a potentially fatal but preventable illness that causes disease, disability, and premature death, especially among adolescent females using high absorbency tampons. In 1983 the authors surveyed 129 high school girls in three midwestern senior high schools to determine the relationship between choice of a menstrual product and knowledge about toxic shock syndrome. The study found that the knowledge level of adolescent females about TSS was fragmented and inaccurate. No significant relationship was found between choice of a menstrual product and knowledge about TSS; very little variation existed between the scores for napkin users, regular tampon users, and high absorbency tampon users. Results of the study are discussed in terms of the implications for the health of adolescent females. Recommendations are offered for utilizing health professionals, parents, and the news media in the development of toxic shock education programs.