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Couldn’t help taking a break from pure diagnosis to share a few marvelous articles I just read. All are from the CDC’s Morbidity & Mortality Weekly Reports (MMWR), of which I’ve been an enormous fan for many years. It’s usually staid epidemiology, documenting recent trends which are interesting but rarely momentous. Yet in & around the statistics, some fascinating reports creep up.
1) “Acute Mercury Poisoning After Home Gold & Silver Smelting” (12/18/15). A 59-y.o. man hit the ER with dyspnea, tremors, anorexia, & generalized weakness. He’d been using mercury with hydrogen peroxide, nitric acid, hydrochloric acid, and sulfuric acid to recover gold from computer components, in a frying pan on his kitchen stove. His military gas mask didn’t help, so he wound up on a respirator, in an ICU for 4 weeks, followed by a SNF for ongoing oxygen due to chemical pneumonitis.
The authors identified 200,000 websites, including 12,000 videos, describing how to use mercury to extract gold & other precious metals from old computer parts. Among a convenience sample of 30 videos, only 5 described possible dangers & useful safety precautions. Add mercury poisoning to the differential of patients in acute distress with global symptoms.
2) “Group A Strep Pharyngitis Misdiagnoses at a Rural Urgent-Care” (1/1/16). A Wyoming clinic serving population of 7,000 called the state for help after diagnosing up to 90 cases of Strep throat per week during several months. Some didn’t respond to penicillin or amoxicillin, leading clinicians to begin using cephalosporins, Augmentin®, or clindamycin.
Many patients were asymptomatic, many others had classic viral URI symptoms. The state found 86% positive results in a convenience sample of recent tests. When it tried confirming some by culture, all were negative. A few subsequent positive cultures were all Pen-sensitive, as expected.
As it turned out, lots of the swabs were left to incubate over the manufacture-recommended time (5 min.), a cause of false-positivity. Asymptomatic positives were likely carriers, as are 10% to 20% of many populations. The clinic was indirectly commended for requesting help.
Moral (in addition to assuring that ancillary staff use clocks to exactly time the various point-of-care tests they do) — Don’t test for Strep in patients without sore throat. Don’t test household contacts who aren’t ill (especially not children under 3 y.o.). Only test patients with ≥3 Centor Criteria:
- Exudate on tonsils
- Tender anterior cervical nodes
- Fever (OK if by history)
- No cough
The main reason to treat Strep throat is to prevent acute rheumatic fever (ARF), which is very rare in developed countries these days. Most common age for ARF is 5-15, virtually never >30. Of course, anyone who ever had rheumatic fever (especially carditis) should be immediately treated for any pharyngitis. I work with immigrants, routinely ask about this when someone has a sore throat, & every so often get a “yes.”
In the age of emerging antimicrobial-resistant pathogens, Streptococcus pyogenes and Treponema pallidum (syphilis) remain 100% senesitive to penicillin. There’s hope they may stay that way.
3) “Rabies in a Dog Imported from Egypt with a Falsified Rabies Vaccination Certificate” (12/18/15). An American animal rescue organization shipped 8 dogs and 27 cats it scooped up from streets in Cairo, for adoption in the US. One dog had rabies; its vaccination certification was intentionally predated. Its caretaker in the US was pet sitting a neighbor’s dog & caring for 8 other dogs, plus 9 other animals.
For those interested in human rabies, patients present with non-specific symptoms like fever, malaise, myalgias, nausea, headache, etc., then become frankly encephalopathic. If noted, pharyngeal spasms & terror when attempting to drink (hydrophobia) or when air is fanned across the face (aerophobia) may be pathognomonic. A prodromal clue may include tingling or other sensory phenomena radiating proximally from the bite site. In the paralytic form of disease, which resembles Guillain-Barré, a very brief mounding of muscle (myoedema) upon percussing the deltoid, chest, or thigh suggests rabies.
Fortunately, in this instance animal rabies got identified in time, and 18 people received post-exposure prophylaxis. In its typically understated style, MMWR authors opined, “Considering…the current oversupply of adoptable animals already in the US, persons & organizations…importing pets for…adoption should consider reevaluating, and potentially redirecting, their current efforts.”
4) “Injection Safety and Vaccine Administration Errors at an Employee Influenza Vaccination Clinic” (12/18/15). An “experienced nurse” was contracted to vaccinate company employees against the flu. She stored vials in her home refrig (without temperature monitoring), & reused the 2 syringes “she found among her supplies.” Did employ fresh needles, but since there were too many recipients for the 2 vials, some/all got under-dosed.
Someone complained. The nurse “voluntarily surrendered her license”. I suppose “experienced” here is a proxy for “older / retired” [disclosure: I’m older, tho not retired]. Reminds me of a scandal years ago when an experienced doctor gave flu vaccine to 2 news anchors on live TV, wiping the same needle with alcohol between shots [my emphasis].
Nobody contracted anything (though maybe eventually the flu???). So much for “experience”.
5) “Fatal Bacterial Meningitis Possibly Associated with Substandard Ceftriaxone – Uganda” (1/1/16). A 13-y.o. boy in Kampala died of likely meningitis despite timely antibiotics. The University of Ottawa (Canada) subsequently analyzed one of the hospital’s typical ceftriaxone vials, & found <50% of the labeled drug dosage. The article’s discussion notes a recent meta-analysis for over 2,000 samples in 21 African countries found 35% failed chemical analysis, & 20% appeared falsified. Similar findings in Pakistan.
How sad.
CONCLUSION — The above examples demonstrate why I don’t read many novels these days; non-fiction is so much more fascinating.
DiagnosisDude 