Transcript 3. List differential diagnoses for the neck swelling in this patient

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1. Enumerate the classification
criteria for SLE
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Diagnostic Criteria for SLE
Malar rash
Flat/raised fixed erythema over malar eminences
Discoid rash
Erythematous circular raised patches with adherent keratotic scaling and
follicular plugging; atrophic scarring may occur
Photosensitivity
Exposure to UV light causes rash
Oral ulcers
Oral and nasopharyngeal ulcers observed by physician
Arthritis
Non-erosive, 2 or more joints; with tenderness, swelling, or effusion
Serositis
Pleuritis or pericarditis (by ECG or rub or evidence of effusion)
Renal disorder
Proteinuria > 0.5g/d or  3+, or cellular casts
Neurologic disorder
Seizures or psychosis, no other causes
Hematologic disorder
Hemolytic anemia or leukopenia (<4000/uL) or lymphopenia (<1500/uL) or
thrombocytopenia (<100,000/uL) in the absence of offending drugs
Immunologic disorder
Anti-dsDNA, anti-Sm, and/or anti-phospholipid
Antinuclear antibodies Abnormal titer by immunofluoresence or equivalent assay at any point in
time in the absence of drugs known to induce ANA
Harrison’s Principles of Internal Medicine, 17th ed.
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2. List differential diagnoses for
muscle weakness and elevated
creatine kinase
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Polymyositis
• Polymyositis is an uncommon connective
tissue disease. It's a type of inflammatory
myopathy, which is characterized by muscle
inflammation and weakness.
• Women between their 30s and 50s
• A blood test will let your doctor know if you
have elevated levels of muscle enzymes, such
as creatine kinase (CK) and aldolase.
http://www.medicinenet.com/polymyositis/article.htm
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Amyotrophic Lateral Sclerosis
• Amyotrophic lateral sclerosis (ALS) is a rare,
progressive neurological disorder in which
nerves that control the body's muscle activity
deteriorate (degenerate)
• ALS is characterized by the presence of
extremity (distal) weakness with the presence
of upper motor neuron signs.
• blood studies (serum creatine kinase may be
elevated)
http://www.mdguidelines.com/amyotrophic-lateral-sclerosis
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Systemic Lupus Erythematosus
• Systemic lupus erythematosus (SLE) is a
multisystem autoimmune connective tissue
disorder with various clinical presentations.
• Muscle enzyme levels (creatine kinase,
aldolase) may be moderately or severely
elevated with lupus myopathy
http://emedicine.medscape.com/article/1146456-overview
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3. List differential diagnoses for the
neck swelling in this patient
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DIFFERENTIAL DIAGNOSES
1. Diseases with Cervical lymphadenopathy (e.g.
Tuberculosis, Lymphoma, Tonsilitis)
2. Ludwig’s angina
3. Upper Respiratory tract Infection esp.
Pharyngitis
4. Lymphoma
5. Infectious mononucleosis
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Cervical Lymphadenopathy
• Cervical nodes drain the tongue, external ear,
parotid gland, and deeper structures of the
neck, including the larynx, thyroid, and
trachea.
• Inflammation or direct infection of these areas
causes subsequent engorgement and
hyperplasia of their respective node groups.
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Ludwig’s Angina
• Ludwig's angina, otherwise known as angina ludovici, is a
serious, potentially life-threatening cellulitis or connective
tissue infection, of the floor of the mouth, usually occurring
in adults with concomitant dental infections.
• Symptoms: swelling, pain and raising of the tongue,
swelling of the neck and the tissues of the submandibular
and sublingual spaces; malaise, fever, dysphagia (difficulty
swallowing) and, in severe cases, stridor or difficulty
breathing.
• Swelling of the submandibular and/or sublingual spaces are
distinctive in that they are hard and classically 'boardlike‘.
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URT Infection (Pharyngitis)
• Pharyngitis is inflammation of the pharynx, which is in
the back of the throat, between the tonsils and the
voicebox (larynx).
• The main symptom is sore throat.
• Other symptoms may include:
-Fever
-Headache
-Joint pain and muscle aches
-Swollen lymph nodes in the neck
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Hodgkin’s disease
• Hodgkin's disease, also called Hodgkin’s
lymphoma, is the result of change or mutation
in infection-fighting white blood cells called
lymphocytes, which are stored in the lymph
glands. This change results in an uncontrolled
growth of cancer cells, which develop into
malignant tumors in the lymph glands.
Hodgkin's disease can also develop in other
parts of the lymphatic system, such as the
spleen or bone marrow.
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Infectious Mononucleosis
• a generalized infection ,caused by a virus, either
the EBV or CMV.
• spreads from person to person through intimate
contact with the saliva of a person who has
mononucleosis (“kissing disease”).
• Early flu-like symptoms,classic symptoms develop
later and include swollen glands and extreme
fatigue
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Mumps
• caused by the mumps virus. Before the development of
vaccination and the introduction of a vaccine, it was a
common childhood disease worldwide, and is still a
significant threat to health in the third world.
• Painful swelling of the salivary glands (classically the
parotid gland) is the most typical presentation. The disease
is generally self-limited, running its course before receding,
with no specific treatment apart from controlling the
symptoms with painkillers.
• May spread to other areas such as the neck and the
testicles for males.
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4. What are some underlying factors
and etiologic organisms in Ludwig’s
angina?
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Ludwig’s angina
• Ludwig’s angina is a rapidly progressive,
potentially fulminant cellulitis
• involves the sublingual and submandibular
spaces
• typically originates from an infected or
recently extracted tooth
– lower second and third molars
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• Spread of process superiorly and posteriorly elevates
floor of mouth and tongue.
• In anterior spread, the hyoid bone limits spread
inferiorly, causing a "bull neck" appearance
Am Fam Physician 1999;60:109-12
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Predisposing factors
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dental caries
recent dental treatment
sickle cell disease
a compromised immune system
trauma
tongue piercing
Am Fam Physician 1999;60:109-12
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Etiologic Organisms
Common
• Staphylococcus
• Streptococcus
• Bacteroides
Atypical
• Pseudomonas
• Escherichia coli
• Klebsiella
• Enterococcus faecalis
• Candida
• Clostridium
Crit Care Clin. 2003;19:55-72
J Emerg Med. 1995;13:499-503
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5. Define and distinguish the
etiologic organisms in community
azquired pneumonia vs hospitalacquired pneumonia
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Community acquired pneumonia
• is a disease in which individuals who have not
recently been hospitalized develop an
infection of the lungs (pneumonia)
• occurs throughout the world and is a leading
cause of illness and death.
• bacteria, viruses, fungi, and parasites.
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Most common etiologic organisms…
• Infants
– caused by Streptococcus agalactiae, also known as
Group B Streptococcus or GBS. GBS causes at least
50% of cases of CAP in the first week of life.
– Other bacterial causes in the newborn period
include Wisteria monocytogenes and tuberculosis.
– In cases of viruses herpes simplex virus is the most
common and life-threatening, but adenovirus,
mumps, and enterovirus can also cause disease
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• Infants
– Streptococcus pneumoniae, Escherichia coli,
Klebsiella pneumoniae, Moraxella catarrhalis, and
Staphylococcus aureus.
– Chlamydia trachomatis-acquired during birth but
which does not cause pneumonia until 2–4 weeks
later
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• Adults
– Viruses
• 20% of CAP cases.
• influenza, parainfluenza, respiratory syncytial virus,
metapneumovirus, and adenovirus
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• Adults
– Streptococcus pneumoniae
• common bacterial cause of CAP
• "drug resistant Streptococcus pneumoniae" or DRSP older than 65, exposure to children in day care, having
alcoholism or other severe underlying disease, or
recent treatment with antibiotics should initially be
treated with antibiotics effective against DRSP.
– Atypical organisms
• Mycoplasma pneumoniae and Chlamydophila
pneumoniae.Legionella pneumophila
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• Adults
– Hemophilus influenzae
– Enteric Gram negative bacteria - Escherichia coli
and Klebsiella pneumoniae
• residence in a nursing home, serious heart and lung
disease, and recent antibiotic use should initially be
treated with antibiotics effective against Enteric Gram
negative bacteria.
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Risk Factors
• Obstruction
• Lung disease
• Immune problem
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Hospital-acquired pneumonia
• develops at least 48 hours after hospital admission
• microaspirationof bacteria that colonize the
oropharynx and upper airways in seriously ill patients
• Hospital-acquired pneumonia (HAP) includes:
– ventilator-associated pneumonia (VAP)
– postoperative pneumonia
– pneumonia that develops in unventilated but otherwise
moderately or critically ill hospitalized inpatients
– healthcare-associated pneumonia (HCAP) - pneumonia
acquired by patients in healthcare facilities such as chronic
care facilities, dialysis centers, and infusion centers
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Risk Factors
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mechanical ventilation
Old age
Decreases filtration of inspired air
Other disease states
Medications
Poor hand-washing
Inadequate disinfection of respiratory devices
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Most common etiologic organisms…
• aerobic gram-negative bacilli:
– P. aeruginosa
– Escherichia coli
– Klebsiellapneumoniae
– Acinetobacter species
• gram-positive cocci
– Staphylococcus aureus, particularly methicillinresistant S. aureus (MRSA)
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• Fungal pathogens:
– Candida species
– Aspergillusfumigatus
• Viral Pathogens:
– Influenza
– parainfluenza,
– adenovirus,
– measles,
– respiratory syncytial virus