In morning report,
we discussed the case of a man with HIV presenting with sepsis and odynophagia
with head and neck lymphadenopathy and symptoms of sinusitis.
We discussed the
following learning points:
1.
Head and neck infection: a history of odynophagia, lymphadenopathy
and sinusitis is concerning for a head and neck infection. The differential
diagnosis would include:
a.
Deep neck
space infections such as retropharyngeal abscesses
b.
Peritonsillar
abscesses and submandibular space infections (Ludwig’s angina)
c.
Suppurative
parotitis
d.
Pharyngitis
e.
Lymphadenitis
(including TB lymphadenitis)
f.
Epiglottitis
g.
Laryngotracheitis
h.
Diphtheria
2.
CD4 count : we discussed that the differential diagnosis will
change and be informed by the opportunistic infections that patients with HIV
are susceptible to with different CD4 counts:
3.
Meningitis examination: With the history of fever and headache, the
question of meningitis comes up. Looking at the JAMA Rational Clinical
Examination article on “Does this adult patient have acute meningitis?” from
1999, absence of fever, neck stiffness and altered mental status effectively rules
out meningitis. One of the most sensitive maneuvers in the diagnosis of meningitis
is jolt accentuation (sensitivity 100%, specificity 54%, positive LR 2.2,
negative LR 0); a negative jolt accentuation may essentially exclude
meningitis.
In this case, there
was no evidence of meningitis on exam (negative jolt accentuation) and swabs
and blood cultures were positive for Group
A Streptococcus (Sterptococcus pyogenes).
4.
Group A
Streptococcus (GAS) infections:
Types of GAS
infection include:
-
Streptococcal
tonsillopharyngitis “strep throat”
-
Skin
and soft tissue infections
o
Cellulitis
o
Erysipelas
-
Necrotizing
fasciitis
-
Myositits
-
Pneumonia
-
Postpartum
endometritis
-
Bacteremia
associated with toxic shock syndrome
Nonsuppurative Complications
of GAS pharyngitis include:
-
Scarlet
Fever
-
Rheumatic
Fever
-
Glomerulonephritis
-
Toxic
Shock Syndrome
Treatment of GAS:
-
GAS is
universally sensitive to penicillin and as such penicillin is the first line
treatment.
-
Clindamycin
is generally used in addition to a beta-lactam in the treatment of invasive GAS
has it inhibits protein synthesis, suppressing synthesis of bacterial toxins,
and there is evidence that it reduces mortality.
-
For
toxic shock syndrome, there is some evidence supporting the adjunctive use of
IVIG
-
Don’t
forget that early aggressive surgical intervention is key for invasive soft
tissue infections, such as necrotizing fasciitis.
References:
Attia et al. Does
this adult patient have acute meningitis? JAMA. 1999;282(2):175-81.
Carapetis et al.
Effectiveness of clindamycin and intravenous immunoglobulin, and risk of
disease in contacts, in invasive group A streptococcal infections. Clin Infect
Dis. 2014;59(3):358.
Davies et al.
Invasive Group A Streptococcal Infections in Ontario, Canada. NEJM.
1996;335:547-54.
Wessels.
Streptococcal Pharyngitis. NEJM. 2011;364:648-55.
