POTD: Varicella-zoster virus (VZV)

Noticing the trend in decreased vaccination, let’s review varicella.

• Varicella-zoster virus (VZV): one of eight herpesviruses known to cause human infection

• full-body rash that starts on the trunk and is characterized by lesions in various stages of development.

  • Buzz words: asynchronous vesicular lesions

·      Requires airborne precautions

·      Chickenpox used to be very common in the United States.

o    Each year, chickenpox caused about 4 million cases, about 10,600 hospitalizations and 100 to 150 deaths.

·      Two doses of the vaccine are about 90% effective at preventing chickenpox.

·      Although varicella is usually a self-limited disease and usually management is supportive

o   Exception to this is if you are at risk for complication or develop complications. 

·      Who is most at risk for complications from varicella?

o   Older patients, pregnant patients, and anyone who is immunocompromised (think on chronic steroids or immunosuppressants who are not vaccinated).

·      Complications: hepatitis, pneumonia, superimposed cellulitis, meningitis and encephalitis

·      Pneumonia is more frequent complication in these at risk populations (especially pregnant patients) who develop varicella.

·      Severe complications of varicella pneumonia in pregnant patients: development of congenital varicella syndrome in the baby and, if the mother develops varicella rash right before or after delivery, risk for neonatal varicella.

·      When associated with pregnancy, varicella pneumonia is the leading cause of varicella-related illness and death in adults, with a reported maternal mortality rate of up to 44%.

·      Patients with severe varicella disease should be admitted and treated with intravenous acyclovir.

o   Special attention to airway monitoring

·      When do we give Varicella-zoster immune globulin (VZIG)?

o   VZIG is indicated for prophylaxis in susceptible pregnant women who have been exposed to the varicella-zoster virus.

o   The primary purpose of VZIG prophylaxis is to prevent or attenuate maternal disease.

·      PO acyclovir for those cases that are not severe and can be managed with close outpatient follow up

Sources:

https://www.cdc.gov/vaccines/vpd/varicella/index.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155623/

Peer IX

Uptodate: varicella: https://www.uptodate.com/contents/treatment-of-varicella-chickenpox-infection

POTD: TB in the ED

Approach to TB in the ED.

TB might be more common than you think: In NY alone, in 2016, 3.9 cases per 100,000 people, 761 cases in NY in 2016.

Reactivation TB is about 90% of active TB in the United States. 

Who is at high risk?

Those with no “usual source of care”

• ethnic minorities

• foreign born

• HIV patient

• drug users

• nursing home patients

• homeless patients

• prisoners

Why is it often missed?

Non-specific presentation of TB

• Cough present: 64%

• Cough was chief complaint: 20%

• Only 36% had respiratory complaint at triage

What to do if for high suspicion of TB:

• Negative pressure isolation room

• N95 fitted masks

• CXR and rapid HIV

  • Why HIV test?

    • HIV increases risk of having reactivation TB

    • Immunosuppression will give you atypical cxr findings

• Looking primarily for active tuberculosis 

Confirmatory testing:

• PPD: Sensitivity 60-100%

• QuantiFERON Gold: Sensitivity 81-96%

• Sputum Looking for AFB on smear (Ziehl-Neelson stain)

  • Variable Sensitivity: 20-60%

  • High specificity: 90-100%

• Culture

  • Slower results: 7days- 8 weeks

  • Gold standard: 99% sensitivity

• Rapid TB testing/ Cepheid Xpert MTB/RIF PCR assay

  • Respiratory for assistance in collection

  • 5 ml specimen

  • Rifampin resistance detection

  • Supposed to be a 2 hr turnaround

  • 2 negative sputum specimens at least 8 hrs apart: can remove from isolation

  • Sensitivity about 75-93%

*This is a sample rule out TB protocol that I adapted from Annals of Emergency Medicine October 2016 : http://www.annemergmed.com/article/S0196-0644(16)30920-9/fulltext

POTD: Ludwig’s Angina

History: Named after German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836.

Overview:

•        Submandibular Space Cellulitis

•        Bilateral

•        Aggressive, fast spreading

•        70% of Ludwig’s angina is dental in origin

•        Real risk of airway compromise: This can result in rapid airway decompensation.

Physical Exam (useful things to document the presence of absence of in the chart):

•        Floor of the mouth: is described as: “woody,” which means firm, indurated, taut

•        Tongue: displaced superiorly and posteriorly

•        This result in: Slow suffocation, drooling, sniffing position, muffled voice, stridor

•        Labs

•        Vbg, cbc 7, blood cultures

•        Imaging

•        CT face and neck with IV contrast

•        Be very cautious if you are sending them to CT without airway secured

•        Consults

•        ENT, anesthesia

Treatment

•        ABCs…A! Airway obstruction in 33%

•        sit upright

•        Secure/verify integrity of airway

•        Awake fiberoptic nasal intubation

•        Mentally prepare yourself for a surgical airway. This is the time to have the materials set up at the bedside.

•        Abx: polymicrobial

• Oral anaerobes and aerobes

• PCN G + flagyl

• Unasyn

• Clinda

• Immunocompromised? Cefepime +flagyl

•        Steroids

• Dexamethasone  8-12 mg IV

•        Dispo

• ICU

• 3-4 day process, gets worse before better

Complications

•        Mortality usually associated with airway compromise

•        with appropriate treatment, 8% mortality

•        Spread of infection: IJ thrombophlebitis, intracranial infection, mediastinitis

Brush up!

Sources: LIFL https://lifeinthefastlane.com/ccc/ludwigs-angina/

Uptodate Lugwig’s angina

Tintinelli’s Lugwig’s angina