NMS Q&A Family Medicine

Other Infectious Diseases in Primary Care 193more likely in elderly and infirm. Typhoid and meningococcusmust be ruled out.About 10% occur without a rash. Diagnosis is madeby serial serological studies, a process that may take2 weeks, or by immunofluorescent antibody. The rash ofRubeola is morbilliform (i.e., like measles), not macularnor petechial. Meningococcemia, because of the seriousness,must be considered and ruled out. Varicella, chickenpox,presents with a centripetal vesicular rash, asopposed to the mostly centrifugal distribution of therash of RMSF, albeit spreading centripetally. Typhoidfever is characterized by a rash, but nearly always manifestsgastrointestinal symptoms, usually evolving into“soupy diarrhea.” Diagnosis of meningococcal meningitisis made by spinal tap for identification of Neisseriameningitidis , presumptively by smear and definitively byculture. Doxycycline or tetracycline is the treatment ofchoice for RMSF, even in children, continued until 3 daysafter defervescence. Chloramphenicol is effective but isreserved for pregnant women to avoid tetracycline sideeffects in the fetus. The other agents mentioned are noteffective.7. The answer is E. Kawasaki disease is the only entityamong the choices that fits the clinical picture presented.The disease is an inflammatory response to an unknownagent, perhaps one of several that may engender the vasculitisthat is the essence of the disease. Asians are moresusceptible. Timely diagnosis is important to prevent vasculitides,especially coronary vasculitis that can lead tomyocardial infarction. Roseola affects younger childrenand is characterized by very high fever for several daysthat breaks precisely as a morbilliform rash appears.Rubeola features high fever, malaise, and the generalizedmorbilliform rash that appears along with the first symptomsand persists throughout, as do the Koplik spots thatare most often seen opposite the second molars or in thevaginal mucosa. Rubella is also called the “three day measles,”and the adenopathy occurs in the retroauricular andsubocciputal regions. Scarlatina is “scarlet fever,” a GroupA beta-hemolytic streptococcal infection that releases theerythrotoxin. With the cervical adenopathy and thedesquamation of the fingertips, scalatina must be consideredas well, but can easily be diagnosed as streptococcusdisease with the 10-minute flocculation “Rapid Strep”screen from the pharynx. Erythema infectiosum is “fifthdisease,” occurs in infants younger than 2 years, and isknown for the slapped cheek appearance, caused by a diffuseflush as opposed to the other rashes described in thisvignette. Therapy of Kawasaki syndrome is based on antiinflammatorymodalities, for example, aspirin and, in theopinions of some, glucosteroids. Diagnosis is based onfever lasting at least 5 days and satisfaction of clinical criteriaas in other inflammatory conditions. Four of the followingclinical criteria must be met:1. Bilateral non-exudative conjunctivitis2. Mucous membrane changes of at least one of thefollowing types: injected pharynx, erythema, swellingor fissure of the lips, strawberry tongue3. Peripheral extremity changes, palmar or solar erythema,desquamation, induration or Beau’s lines (transversegrooves in the fingernails)4. Polymorphous rash5. Cervical lymphadenopathy8. The answer is D. Toxic shock syndrome now occurs asfrequently in non-female menstrual situations as in theoriginally described association with the retained tampon.The vesicular changes of the palms and soles lead tothe well-known desquamation seen in the late stages.Toxic shock, which may carry a case mortality as high as15% as a result of hypotension and heart failure, is due tothe toxin elaborated. Thus, early cultures may be unhelpful.Scarlatina may be considered long enough to rule outquickly because the rash of scarlatina is quite different,described as pampiniform (pinpoint red spots). Kawasakisyndrome occurs nearly always in children 5 years old oryounger, albeit characterized by desquamation of thepalms and the soles. Although secondary syphilis manifestspalmar and solar changes, they are nonvesicular andconsist of macules, papules, and pustules. Cirrhosis of theliver is mentioned because of palmar erythema seen in theface of patients with advanced compromise of liver function.Again, however, vesicle formation and desquamationis not characteristic of such a situation.9. The answer is E. Febrile disease associated with a newheart murmur or a changing heart murmur must be consideredto have bacterial endocarditis until proven otherwise,by serial blood culture. The disease is also calledinfectious endocarditis to distinguish it from autoimmuneendocarditis. The major risk factors are previousvalvular heart disease and intravenous drug abuse. However,neither of the foregoing may be present for there tobe bacterial endocarditis. The painful lesions of the fingersand toes fit the description of Osler’s nodes. Otherstigmata of endocarditis of bacterial endocarditis includeJaneway nodes (painless erythematous lesions of thepalms or soles), splinter hemorrhages of the nails, andRoth spots (retinal exudates). Although the patient is atrisk for hepatitides B and C because of his drug abusehistory, and thus they should be ruled out in any febrileillness, they do not present with heart murmurs nor arewell known for skin lesions. Meningococcemia is unlikelyin the absence of meningismus. S. aureus causes 60% ofendocarditis cases in intravenous drug users. This haseffected a change in the overall concepts of bacterial endocarditisover the past 30 years. Staph disease in endocarditisfollows a more acute course than Streptococcus viridansdisease; thus, in the past, the synonym for endocarditiswas subacute bacterial endocarditis , or SBE.