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NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .

Tuesday, December 30, 2014

A 26-year-old woman travels to a rural area of Nepal.

A 26-year-old woman travels to a rural area of Nepal. Three days after arrival, she develops watery diarrhea with severe abdominal cramping.

She reports two unformed stools daily for the past 2 days. She has noticed no blood in the stool and has not experienced a fever.

What is the most likely cause of the patient’s illness?

A. Campylobacter jejuni
B. Enterotoxigenic Escherichia coli
C. Giardia lamblia
D. Norovirus
E. Shigella spp.

The answers is B  Traveler’s diarrhea is common among individuals traveling to rural affecting 25% to 50% of travelers to these areas. Most traveler’s diarrhea begins within
3 to 5 days after arrival and is self-limited, lasting 1 to 5 days. Most individuals acquire
traveler’s diarrhea after consuming contaminated food or water. Although some organisms
have a geographic association, enterotoxigenic and enteroaggregative Escherichia
coli are found worldwide and are the most common causes of traveler’s diarrhea.

In Asia, Campylobacter jejuni is also common. This presentation would be uncommon for
Shigella spp. because it most frequently causes bloody diarrhea. Norovirus is associated
with a more profuse diarrhea. It has been the causative organism in large outbreaks on
cruise ships. Giardia lamblia is a parasite that is responsible for 5% or less of traveler’s

Monday, December 29, 2014




Pellagra is a disorder caused by defi ciency of nicotinic acid (niacin, vitamin B3) or its precursor, tryptophan.


● Dietary defi ciency (alcoholism, malabsorption, anorexia nervosa, socioeconomic deprivation)
● Carcinoid tumors (excessive use of tryptophan, which produces serotonin)


● The skin eruption is photosensitive. An initial, painful, sunburn-like erythema subsides to leave a dusky brownish discoloration, with a dry scaly appearance .
● Other features sometimes present include cheilosis, glossitis, angular stomatitis, and oral or perianal sores.


Legs and feet of a patient with niacin deficiency. A, Before therapy. B, After therapy.
● Nutritional supplementation with niacin will improve the appearance of skin lesions .

Saturday, December 27, 2014

A 42-year-old man with poorly controlled diabetes (HbA1c, 13.3%) presents with thigh pain and fever over several weeks.

A 42-year-old man with poorly controlled diabetes (HbA1c, 13.3%) presents with thigh pain and fever over several weeks.

Physical examination reveals erythema and warmth over the thigh with notable woody, nonpitting
edema. There are no cutaneous ulcers. CT of the thigh reveals several abscesses located between the muscle fibers of the thigh. Orthopedics is consulted to drain and culture the abscesses.

Which of the following is the most likely pathogen?

A. Clostridium perfringens
B. Group A streptococcus
C. Polymicrobial flora
D. Staphylococcus aureus
E. Streptococcus milleri

The answer is D.  

This patient has infectious pyomyositis, a disease of the tropics and of immunocompromised hosts such as patients with poorly controlled diabetes mellitus or AIDS. The pathogen is usually Staphylococcus aureus. Management includes aggressive debridement, antibiotics, and attempts to reverse the patient’s immunocompromised status.

 Clostridium perfringens may cause gas gangrene, particularly in devitalized tissues. Streptococcal infections may cause cellulitis or an aggressive fasciitis, but the presence of abscesses in a patient with poorly controlled diabetes makes staphylococcal infection more likely.

Polymicrobial infections are common in diabetic ulcers, but in this case, the imaging and physical examination show intramuscular abscesses.

E. Staphylococcus epidermidis

Which of the following organisms is most likely to cause infection of a shunt implanted for the treatment of hydrocephalus?

A. Bacteroides fragilis
B. Corynebacterium diphtheriae
C. Escherichia coli
D. Staphylococcus aureus
E. Staphylococcus epidermidis

The answer is E. Probably because of its ubiquity and ability to stick to foreign
surfaces, Staphylococcus epidermidis is the most common cause of infections of central
nervous system shunts as well as an important cause of infections on artificial heart valves
and orthopedic prostheses.

Corynebacterium spp. (diphtheroids), similar to S. epidermidis,colonize the skin. When these organisms are isolated from cultures of shunts, it is often difficult to be sure if they are the cause of disease or simply contaminants. Leukocytosis in cerebrospinal fluid, consistent isolation of the same organism, and the character of a patient’s symptoms are all helpful in deciding whether treatment for infection is indicated.

Friday, December 26, 2014

ECG: Stenosis of the left anterior descending artery

Patient with chest pain :

Stenosis of the left anterior descending artery

The electocardiogram reveals anterolateral T-wave inversions with biphasic lateral T waves. This finding (Wellens'’ syndrome) is associated with severe stenosis of the left anterior descending artery. Coronary angiography showed stenosis of 95% of the mid-–left anterior descending artery, which was successfully treated with a drug-eluting stent.

Wednesday, December 24, 2014

A 19-year-old man comes to clinic complaining of 2 days of severe dysuria and urethral discharge.

A 19-year-old man comes to clinic complaining of 2 days of severe dysuria and urethral discharge.

Urine analysis shows pyuria. He reports unprotected sexual contact with a new partner within the past week. DNA
probe is positive for N. gonorrhea.

Uretheral discharge with pus

Which of the following is the most effective therapy?

A. Intravenous ceftriaxone
B. Intramuscular penicillin
C. Oral azithromycin
D. Oral cefixime
E. Oral levofloxacin

The answer is D. Because of emerging resistance, treatment recommendations for gonorrhea require frequent updating. Fluoroquinolones and penicillin are no longer generally recommended in the United States because of resistance. Current effective therapies use single-dose therapies to maximize adherence.

Oral cefixime or intramuscular ceftriaxone are effective for urethritis, cervicitis, and proctitis. Azithromycin is no longer effective for gonorrhea because of resistance, but it should be administered because of the presumption of chlamydial co-infection. Doxycycline also an option for co-treatment in nonpregnant women. Patients with uncomplicated infection who receive therapy do not require a test of cure. Patients should be instructed to contact sexual partners for screening and therapy.

Recent studies have demonstrated that the provision of medications or prescriptions to treat gonorrhea and chlamydia in sexual partners diminishes the risk of reinfection in the affected patient.

Tuesday, December 23, 2014



darkly pigmented macular lesions onthe lips.


This autosomal dominant disease is characterized by GI polyps and pigmented macules with involvement of the perioral skin, lips Fig.  buccal mucosa, and hands and feet, particularly
the palms, soles, fi ngers, and toes.

● Lesions are brown or black and usually measure less than 5 mm in diameter. Skin lesions may fade at puberty but mucosal lesions tend to persist.

Monday, December 22, 2014



Darier’s disease. Lesions may be induced by stress, heat, sweating,and maceration.

● Rare skin disorder usually transmitted in an autosomal dominant pattern.

● It is characterized by abnormal keratinocyte adhesion.

● The lesions are frequently itchy and characterized by greasy, crusted, keratotic yellow-brown papules and plaques found particularly on the scalp, forehead, ears, nasolabial folds, upper chest, back, and supraclavicular fossae.

● Lesions may be induced or exacerbated by stress, heat, sweating, and maceration (Fig.)

● Nail changes are a particularly important diagnostic feature. Longitudinal white or red streaks (often both), some of which terminate in a small nick on the free margin, are
typical fi ndings (Fig. ).

● Patients with Darier’s disease are susceptible to bacterial (particularly Staphylococcus aureus), dermatophytic, and viral infections.

● Diagnosis: skin biopsy reveals focal acantholytic dyskeratosis.

● Treatment: emollients, cool cotton clothing, topical or oral retinoids, topical 5-fl uorouracil

Saturday, December 20, 2014



Leser-Trélat sign (A, B). The sudden onset of numerous seborrheic keratoses may indicate an underlying malignant visceral neoplasm

● Seborrheic keratosis are common skin lesions, developing in middle-aged and older adults.

● They are frequently numerous and appear as sharply delineated, round or oval, fl esh-colored or brown-black warty
plaques with a rather greasy texture (Fig.). Although they may be found anywhere on the body (except palms
and soles), they are particularly common on the face, chest, and back.

● A sudden onset of numerous seborrheic keratoses (Leser- Trélat sign)has been reported in association with
internal malignancy, most commonly adenocarcinoma of the stomach. It has also been described after treatment with

● Treatment involves curettage and cautery, cryotherapy, chemical peels, and laser therapy.

Friday, December 19, 2014

A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists.

A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists.

Two weeks earlier, she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. 

On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. 

Which of the following tests is most likely to reveal her diagnosis?

A. Antinuclear antibody
B. Chlamydia trachomatis ligase chain reaction of the urine
C. Joint aspiration for crystals and culture
D. Parvovirus B19 IgM
E. Rheumatoid factor

ans :

The answer is D.  The most likely diagnosis based on the patient’s antecedent illness with a facial rash is parvovirus infection. Arthropathy is uncommon in childhood parvovirus infection but may cause a diffuse symmetric arthritis in up to 50% of adults.

This corresponds to the immune phase of illness when immunoglobulin M antibodies are developed. The arthropathy syndrome is more common in women than men. The distribution of affected joints is typically symmetric, most commonly in the small joints of the hands and less commonly the ankles, knees, and wrists. Occasionally the arthritis persists over months and can mimic rheumatoid arthritis. Rheumatoid factor can be detected in serum. Parvovirus B19V infection may trigger rheumatoid disease in some patients and has been associated with juvenile idiopathic arthritis. Reactive arthritis caused by Chlamydia spp. or a list of other bacterial pathogens tends to affect large joints such as the sacroiliac joints and spine. It is also sometimes accompanied by uveitis and urethritis. The large number of joints involved with a symmetric distribution argues against crystal or septic arthropathy. 

Wednesday, December 17, 2014



● Milia are common superfi cial keratinous cysts that present as white or yellow dome-shaped nodules measuring 1 to 3 mm in diameter. Fig Eccrine hidradenoma. This lesion presents as a solitary nodule, most often on the head and neck or limbs.

● They may represent primary lesions when no cause can be identifi ed or may be secondary variants following skin trauma or other injury.

● Primary milia are seen in up to 50% of newborns and present on the face, upper trunk, and extremities. They typically regress spontaneously. Children and adults can also be affected.

● These lesions are most often apparent on the face (forehead,eyelids, and cheeks; Fig. 25–9) and the external genitalia.

● Diagnostic investigation: microbiology swab for bacteria and yeasts, histology

● Treatment: topical antiseptics, oatmeal baths, frequent showering, topical corticosteroids, systemic antibiotics.

Sunday, December 14, 2014

A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F); sore throat; dysphagia; and a...

A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F); sore throat; dysphagia; and a
number of grayish- white papulovesicular lesions on the soft palate, uvula, and anterior pillars of the tonsils .

. The patient is most likely infected with which of the following?

A. Candida albicans

B. Coxsackievirus

C. Herpesvirus


E. Staphylococcus lugdunensis

The answer is B.These lesions are diagnostic of herpangina, which is caused by coxsackievirus A. They are typically round and discrete, which helps differentiate them from thrush caused by Candida spp. Unlike herpes simplex virus stomatitis, herpangina lesions are not associated with gingivitis. Lesions are typically concentrated in the posterior portion of the mouth. Herpangina usually presents with dysphagia, odynophagia, and fever; these lesions can persist for several weeks. The lesions do not ulcerate.

Thursday, December 11, 2014

A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge.

A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge.

She is sexually active with multiple partners, and she is interested in getting tested for sexually transmitted diseases.

A wet-mount microscopic examination is performed, and trichomonal parasites are identified.

Which of the following statements regarding trichomoniasis is true?

A. A majority of women are asymptomatic.
B. No treatment is necessary because the disease is self-limited.
C. The patient’s sexual partner need not be treated.
D. Trichomoniasis can only be spread sexually.
E. Trichomoniasis is 100% sensitive to metronidazole

The answer is D. Trichomoniasis is transmitted via sexual contact with
an infected partner. Many men are asymptomatic but may have symptoms of urethritis,
epididymitis, or prostatitis. Most women have symptoms of infection that include
vaginal itching, dyspareunia, and malodorous discharge.

These symptoms do not distinguish Trichomonas infection from other forms of vaginitis, such as bacterial vaginosis.

Trichomoniasis is not a self-limited infection and should be treated for symptomatic and public health reasons. Wet-mount examination for motile trichomonads has a sensitivity of 50% to 60% in routine examination. Direct immunofluorescent antibody staining of secretions is more sensitive and can also be performed immediately.

Culture is not widely available and takes 3 to 7 days. Treatment should consist of metronidazole either as a single 2-g dose or 500-mg doses twice daily for 7 days; all sexual partners should
be treated. Trichomoniasis resistant to metronidazole has been reported and is managed
with increased doses of metronidazole or with tinidazole.

A “kissing burn” occurs:

A “kissing burn” occurs:

a. At extensor surfaces in electrical exposure when the current causes flexion at a joint, protecting that area but leaving the exposed extensor surfaces at greater risk for damage.

b. At flexor surfaces in electrical exposure when the current causes flexion at a joint, and the moisture in the flexor crease leads to an arc burn and extensive deep tissue damage.

c. When a child “sucks” an electrical outlet.

d. When a child bites an electric cord.

e. When lightning “kisses” the skin, leaving a typical fernlike pattern.

kissing burn

The answer is b. A peculiar type of burn associated with electrical injury is the kissing burn, which occurs at the flexor creases. As the current causes flexion of the extremity, the skin of the flexor surfaces at the joints touches. Combined with the moist environment that often occurs at the flexor areas, the electric current may arc across the flexor crease, causing arc burns on both flexor surfaces and extensive underlying tissue damage.

Tuesday, December 9, 2014

2-year-old girl whose parents brought her to the emergency department

You are evaluating a 2-year-old girl whose parents brought her to the emergency department after she ingested one pill. After setting up your safety net, you observe her for 6 hours; she is playful and eating normally. 

It would be safe to discharge her if she ingested:

a. Methadone.
b. A sulfonylurea.
c. Citalopram.
d. Iron.
e. Diphenoxylate/atropine (Lomotil).

The answer is d. It is important to know the medications that could be toxic in small quantities (such as one pill or a few drops) in a child. If a child has ingested one of these medications or even if clinical suspicion is high that the child may have ingested one of these medications, the patient must be admitted for 24 hours of observation.

Opioids, especially long-acting preparations like methadone, can lead to lethal respiratory depression and apnea if asmall child ingests one pill. Ingestion of one tablet of sustained release calcium channel and beta-blockers has caused death in children. Long-acting preparations require observation as the onset of symptoms may be delayed.

Sulfonylureas, oral hypoglycemic agents, may cause severe life-threatening hypoglycemia. Evaluation includes frequent blood glucose monitoring for 24 hours. Citalopram and escitalopram in sustained release preparations have been reported to cause seizures, QT prolongation, and torsades de pointes. Children who have ingested one pill need to be monitored for 24 hours. Other substances that are potentially lethal in very small doses include cyclic antidepressants, benzocaine, clonidine, phenothiazines, and theophylline. A few drops of oil of wintergreen (methyl salicylate), methanol, or ethylene glycol can also be lethal in a child. Lomotil is a combination of an opioid and atropine; while the respiratory depression from diphenoxylate can be treated with naloxone, there are
numerous case reports of delayed onset of symptoms even after an extended period of symptom-free observation.

Children may also exhibit delayed onset of atropine intoxication, and death has been reported with ingestion of one pill. Iron overdose can be life threatening, but most poison centers do not make hospital referrals until the ingested dose is greater than 20–60 mg/kg. The amount of iron in vitamins and other preparation varies, but a typical prenatal vitamin contains 65 mg of iron. Iron toxicity is often described in five stages. Stage 1 is the initial symptoms of acute iron poisoning including nausea, vomiting, abdominal pain, and diarrhea. This is followed by the latent stage lasting 6–24 hours. The third stage is the “shock” stage and occurs typically 12–24 hours later.

The fourth stage is hepatotoxicity. The fifth stage includes delayed sequelae and includes gastric outlet obstruction and strictures. If a child presents to the hospital and has no symptoms of iron poisoning, then it is safe to discharge the patient home after 6 hours of observation.

Sunday, December 7, 2014

A lady is contemplating a trekking trip to Nepal at elevations between 2500 and 3000 m.

A lady is contemplating a trekking trip to Nepal at elevations between 2500 and 3000 m.
trekking Nepal

Five years ago, while skiing at Telluride (altitude, 2650 m), she recalls having headache, nausea, and fatigue within 1 day of arriving that lasted about 2–3 days.

All of the following are true regarding the development of acute mountain sickness in this patient EXCEPT:

A. Acetazolamide starting 1 day before ascent is effective in decreasing the risk.
B. Gingko biloba is not effective in decreasing the risk.
C. Gradual ascent is protective.
D. Her prior episode increases her risk for this trip.
E. Improved physical conditioning before the trip decreases the risk.

The answer is E. Whereas acute mountain sickness (AMS) is the benign form of altitude illness, high-altitude cerebral edema (HACE) and high-altitude pulmonary edema (HAPE) are life threatening. Altitude illness is likely to occur above 2500 m but has been documented even at 1500–2500 m. The acclimation to altitude includes hyperventilation in response to the reduced inspired PO2 initially followed by increased erythropoietin and 2,3-bisphosphoglycerate.

AMS is characterized by nonspecific symptoms (headache, nausea, fatigue, and dizziness) with a paucity of physical findings developing 6–12 hours after ascent to a high altitude. AMS must be distinguished from exhaustion, dehydration, hypothermia, alcoholic hangover, and hyponatremia.

The most important risk factors for the development of altitude illness are the rate of ascent and a history of high-altitude illness. Exertion is a risk factor, but lack of physical fitness is not. One protective factor in AMS is high-altitude exposure during the preceding 2 months. Children
and adults seem to be equally affected, but people greater than 50 years of age may be less
likely to develop AMS than younger people. Most studies reveal no gender difference in
AMS incidence.

Sleep desaturation—a common phenomenon at high altitude—is associated
with AMS. Gradual ascent is the best approach to prevent AMS. Acetazolamide or
dexamethasone beginning 1 day before ascent and continuing for 2–3 days is effective if
rapid ascent is necessary. A double-blind placebo-controlled trial demonstrated no benefit
on AMS from gingko biloba. Mild cases of AMS can be treated with rest; more serious
cases are treated with acetazolamide and oxygen.

Descent is therapeutic in all serious cases, including HACE and HAPE. Patients who have recovered from mild cases of AMS may reascend carefully after recovery; patients with HACE should not.

Saturday, December 6, 2014

Which of the following is the most common cause of death from poisoning?

Which of the following is the most common cause of death from poisoning?

A. Acetaminophen
B. Carbon monoxide
C. Chlorine gas
D. Insecticide
E. Tricyclic antidepressants

The answer is B. Most are acute, accidental (unintentional), involve a single agent, occur
in the home, result in minor or no toxicity, and involve children younger than 6 years of
age. Pharmaceuticals are involved in 47% of exposures and 84% of serious or fatal poisonings.
Unintentional exposures can result from the improper use of chemicals at work or
play; label misreading; product mislabeling; mistaken identification of unlabeled chemicals;
uninformed self-medication; and dosing errors by nurses, pharmacists, physicians,
parents, and elderly adults. Excluding the recreational use of ethanol, attempted suicide
(deliberate self-harm) is the most common reported reason for intentional poisoning.
Recreational use of prescribed and over-the-counter drugs for psychotropic or euphoric
effects (abuse) or excessive self-dosing (misuse) are increasingly common and may also
result in unintentional self-poisoning. About 20–25% of exposures require bedside health
professional evaluation, and 5% of all exposures require hospitalization. Poisonings
account for 5–10% of all ambulance transports, emergency department visits, and intensive
care unit admissions. Up to 30% of psychiatric admissions are prompted by attempted
suicide via overdosage. Overall, the mortality rate is low: fewer than 1% of all exposures.
It is much higher (1–2%) in hospitalized patients with intentional (suicidal) overdose,
who account for the majority of serious poisonings. Acetaminophen is the pharmaceutical
agent most often implicated in fatal poisoning. Overall, carbon monoxide is the leading
cause of death from poisoning, but this is not reflected in hospital or poison center statistics
because patients with such poisoning are typically dead when discovered and are
referred directly to medical examiners.

Friday, December 5, 2014

A 32-year-old woman presents to her physician complaining of hair loss.

A 32-year-old woman presents to her physician complaining of hair loss. She is currently 10 weeks postpartum after delivery of a normal healthy baby girl.

She admits to having increased stress and sleep loss because her child has colic.

She also has not been able to nurse because of poor milk production.

On examination, the patient’s hair does not appear to have decreased density. With a gentle tug, more than 10 hairs come out but are not broken and all appear normal. There are no scalp lesions. What do you recommend for this patient?

A. Careful evaluation of the patient’s hair care products for a potential cause
B. Reassurance only
C. Referral for counseling for trichotillomania
D. Treatment with minoxidil
E. Treatment with topical steroids

The answer is B. This patient presents with complaints of diffuse hair loss that has been associated with increased stress as well as hormonal changes after pregnancy and delivery. On physical examination, there is diffuse shedding of normal hairs without scalp lesions or scarring consistent with a diagnosis of telogen effluvium. Telogen effluvium occurs when a stressor causes the typical asynchronous hair growth pattern to become synchronous. This can occur from physical or mental stress (high fever, severe infection) or hormonal changes. When the hair growth becomes more synchronous, more hairs enter the telogen (dying) phase at the same time. The patient may present with complaints of significant hair loss, but hair density to the examiner may appear normal. Broken hairs are not observed, and gentle pulling of the hair results in more than four hairs falling
out. Telogen effluvium is reversible without treatment, and this patient has identifiable
stressors that are related to the cause. Reassurance and observation are all that are recommended.
Some medications can cause telogen effluvium. If identified, these should be
discontinued. In addition, both hyper- and hypothyroidism can lead to the condition.
One should consider evaluation for these and other metabolic disorders if the condition
does not reverse or the patient has additional symptoms.

Other causes of nonscarring alopecia include androgenic alopecia, alopecia areata,
tinea capitis, and traumatic alopecia. Androgenic alopecia is the cause of male and female
pattern baldness. It does not typically result from androgen excess. Rather, it is associated
with an increased sensitivity of the affected hairs to the effects of androgens. Androgenic
alopecia can be treated with minoxidil, finasteride, or hair transplants. Alopecia areata
is a condition of focal hair loss measuring about 2–5 cm in diameter. The surrounding
tissue demonstrates increased T lymphocytes, and the treatment includes intralesional
glucocorticoids or topical anthralin or tazarotene. Tinea capitis is also usually a focal area
of hair loss related to an underlying superficial fungal infection. However, in severe cases,
large plaques and pustules can develop. Treatment with oral griseofulvin or terbinafine
with topical selenium sulfide or ketoconazole is usually effective in treating the disease.
Traumatic alopecia presents with multiple broken hairs at sites of increased stress related
to the use of hair care products, including rubber bands, curlers, or chemicals. It can also
result from trichotillomania. Discontinuation of any offending practice or agent is all that
is required to return the hair to normal. Counseling is typically required for those with

Thursday, December 4, 2014



Charcot-Marie-Tooth disease is a heterogeneous group of noninflammatory inherited peripheral neuropathies. It is the most common inherited neuromuscular disorder.


● Variable presentation from family to family, but affected individuals in a family tend to have similar symptomatology
● Usually, gradual onset, with slowly progressive disorder
● Foot deformity producing a high arch (cavus) and hammertoes
● Atrophy of the lower legs (see Fig.) producing a storklike appearance (muscle wasting does not involve the upper legs
● Nerve enlargement (see Fig.)
● Sensory loss or other neurologic signs, although the sensory involvement is usually mild
● Scoliosis
● Decreased proprioception that often interferes with balance and gait
● Painful paresthesias
● In late cases, possible involvement of hands (see Fig.)
● Absence of deep tendon refl exes (DTRs) in many cases
● Poorly healing foot ulcers in some patients

● Chronic segmental demyelination of peripheral nerves, with hypertrophic changes caused by remyelination

● Other inherited neuropathies
● Toxic, metabolic, and nutritional polyneuropathies

● The early onset, slow progression, and familial nature of the disorder are usually suffi cient to establish diagnosis.
● Electrophysiologic studies are often diagnostic and may also be helpful in defi ning various subtypes of this group of neuropathies.
● Occasionally, muscle and nerve (sural) biopsy may be required

● Genetic counseling
● Supportive physical therapy and occupational therapy
● Prevention of injury to limbs with diminished sensibility
● Bracing
● Occasionally, surgery to add stability and restore a plantigrade foot

Wednesday, December 3, 2014

Which of the following classes of medicines has been linked to the occurrence of hip fractures in elderly adults?

Which of the following classes of medicines has been linked to the occurrence of hip fractures in elderly adults?

A. Benzodiazepines
B. Opiates
C. Angiotensin-converting enzyme inhibitors
D. Beta-blockers
E. Atypical antipsychotics

The answer is A. In population surveys of noninstitutionalized elderly adults,

up to 10% had at least one adverse drug reaction in the prior year. Adverse drug reactions
are common in elderly adults and are related to altered drug sensitivity, impaired renal or
hepatic clearance, impaired homeostatic mechanisms, and drug interactions. Long halflife
benzodiazepines are linked to the increased occurrence of hip fractures in elderly
adults. The association may be caused by the increased risk of falling (related to sedation)
in a population with a high prevalence of osteoporosis. This association may also be true
for other drugs with sedative properties such as opioids or antipsychotics. Exaggerated
responses to cardiovascular drugs such as angiotensin-converting enzyme inhibitors may
occur because of a blunted vasoconstrictor or chronotropic response to reduced blood
pressure. Conversely, elderly patients often display decreased sensitivity to beta-blockers.

Sunday, November 30, 2014

The answer is B. This patient has features of acute delirium, which can be precipitated

You are covering the night shift at a local hospital and are called acutely to the bedside of a 62-year-old man to evaluate a change in his mental status. He was admitted 36 hours previously for treatment of community-acquired pneumonia. He received treatment with levofloxacin 500 mg daily and required oxygen 2 L/min.
He has a medical history of tobacco abuse, diabetes mellitus, and hypertension. He reports alcohol intake
of 2–4 beers daily. His vital signs at 10 pm were blood pressure of 138/85 mmHg, heart rate of 92 beats/min,respiratory rate of 20 breaths/min, temperature of 37.4°C (99.3°F), and SaO2 of 92% on oxygen 2 L/min.

Currently, the patient is agitated and pacing his room. He is reporting that he needs to leave the “meeting” immediately and go home. He states that if he does not do this, someone is going to take his house and car away. He has removed his IV and oxygen tubing from his nose.

His last vital signs taken 30 minutes previously were blood pressure of 156/92 mmHg, heart rate of 118 beats/min, respiratory rate of 26 breaths/min, temperature of 38.3°C (100.9°F),and oxygen saturation of 87% on room air. He is noted to be somewhat tremulous and diaphoretic.

All of the following should be considered as part of the patient’s diagnostic workup EXCEPT:
A. Arterial blood gas testing
B. Brain imaging with MRI or head CT
C. Fingerstick glucose testing
D. More thorough review of the patient’s alcohol intake with his wife
E. Review of the recent medications received by the patient


The answer is B.  This patient has features of acute delirium, which can be precipitated 

by many causes in hospitalized patients. Broad categories of causes of delirium
include toxins, medication reactions, metabolic disorders, infections, endocrine disorders,
cerebrovascular disorders (especially hypertensive encephalopathy), autoimmune
disorders, seizures, neoplastic disorders, and hospitalization. Although the list of causes
is broad, the initial history and physical examination are important to establish potential
etiologies of delirium and guide further workup. In most patients with delirium, it is
difficult to obtain an accurate history; therefore, it is important to seek out a spouse of
family member to outline the history further. In this case, there are features that could
suggest alcohol withdrawal (hypertension, tachycardia, fevers, tremors), and one should
clarify his alcohol intake with his wife. Another primary consideration in determining
the etiology of a delirium episode is the time course over which it evolves and the current
medications. Particularly in older hospitalized individuals, common medications used as
sleep aids, such as diphenhydramine, can have a paradoxical effect with delirium and
agitation. It is estimated that as many as one-third of episodes of delirium in hospitalized
patients are the result of medications. Worsening infection also needs to be considered
because the change in the patient’s vital signs could be indicative of an infectious source,
although the elevated blood pressure is not consistent with this. Because the patient has
required oxygen during his hospitalization, it is important to check an oxygen saturation
or arterial blood gas because acute hypoxemia or hypercarbia can precipitate delirium.
Likewise, given the patient’s history of diabetes mellitus, a fingerstick glucose is necessary
because hypoglycemia could also lead to alterations in mental status with evidence
of tachycardia, tremor, and diaphoresis. Other initial tests to consider in an individual
with delirium are electrolytes and basic liver and kidney function. Although commonly
ordered, brain imaging is most often not helpful in the evaluation of delirium.

Panic disorder ;

Rajendra  is a 20-year-old student who fell to the ground in the supermarket. He did not lose consciousness. He says he suddenly felt very unwell, as if something terrible was going to happen to him.

Then he felt sweaty, he could not breathe properly and his heart began to race as he slumped to the ground. You are seeing him in the Emergency department.

physical tests are normal. However, he continues to appear very anxious. He describes several previous similar episodes over the last 9 months.

he has no psychiatric history, with no recent stressful events. He gets about two of these episodes every month – usually in crowded places – but they are unpredictable.

What is the most likely psychiatric diagnosis here?

Panic disorder.

 Recurrent episodes of sudden onset, severe anxiety symptoms that occur in various (sometimes
similar) situations:
• Episodes are random, and not as predictable as a phobia .
• Episodes usually terminate within minutes, at most 30 minutes
• Panic disorder is frequently associated with agoraphobia (e.g. a specifi c fear of crowds, shopping centres, football grounds)

Saturday, November 29, 2014



Kayser-Fleischer ring.

Wilson’s disease is a disorder of copper transport with inadequate biliary copper excretion, leading to an accumulation of the metal in the liver, brain, kidneys, and corneas.

Hepatic presentation

● Acute hepatitis with malaise, anorexia, nausea, jaundice, elevated transaminase, prolonged prothrombin time; rarely, fulminant hepatic failure

● Chronic active (or autoimmune) hepatitis with fatigue, malaise, rashes, arthralgia, elevated transaminase, elevated serum IgG, positive antinuclear antibody (ANA) and anti– smooth muscle antibody

● Chronic liver disease, cirrhosis with hepatosplenomegaly, ascites, low serum albumin, prolonged prothrombin time, portal hypertension

Neurologic presentation
● Movement disorder: tremors, ataxia
● Spastic dystonia: masklike facies, rigidity, gait disturbance,dysarthria, drooling, dysphagia

Psychiatric presentation
● Depression, obsessive-compulsive disorder, psychopathic behaviors

Other organs
● Hemolytic anemia
● Renal disease (e.g., Fanconi’s syndrome with hematuria, phosphaturia, renal tubular acidosis, vitamin D–resistant rickets)
● Cardiomyopathy
● Arthritis

● Hypoparathyroidism
● Hypogonadism

Physical fi ndings
● Ocular: the Kayser-Fleischer ring is a gold-yellow ring seen at the periphery of the iris (Fig. 40–3)
● Stigmata of acute or chronic liver disease
● Neurologic abnormalities: 

● Dietary copper is transported from the intestine to the liver, where normally it is metabolized into ceruloplasmin. In Wilson’s disease, defective incorporation of copper into ceruloplasmin
and a decrease of biliary copper excretion lead to accumulation of this mineral.

● The gene for Wilson’s disease is located in chromosome 13.

● Hereditary hypoceruloplasminemia
● Menkes’ disease
● Consider the diagnosis of Wilson’s disease in all cases of acute or chronic liver disease in which another cause has not  been established.

● Consider Wilson’s disease in patients with movement disorders or dystonia, even without symptomatic liver disease.

● Abnormal liver function tests (LFTs; note that AST may be higher than ALT)
● Low serum ceruloplasmin level (less than 200 mg/L)
● Low serum copper (less than 65 g/L)
● 24-hr urinary copper excretion more than 100 g (normal, less than 30 g); increases to more than 1200 g/24 hr after 500 mg of D-penicillamine (normal, less than 500 g/24 hr)
● Low serum uric acid and phosphorus
● Abnormal urinalysis (hematuria)

● Early: steatosis, focal necrosis, glycogenated hepatocyte nuclei; may reveal infl ammation and piecemeal necrosis
● Late: cirrhosis 
● Hepatic copper content (less than 250 g/g of dry weight; normal is 20 to 50 g/g)

● Penicillamine, trientine: chelator therapy
● Zinc: inhibits intestinal copper absorption
● Ammonium tetrathiomolybdate for neurologic symptoms
● Antioxidants
● Liver transplantation (for severe hepatic failure unresponsive to chelation)

Friday, November 28, 2014

A 36-year-old woman presented to the accident

A 36-year-old woman presented to the accident and emergency department complaining
of progressively increasing breathlessness over the last 2 weeks. This was accompanied by
a wheeze and cough productive of white sputum. Her exercise tolerance had reduced and
she denied any orthopnoea or chest pain. She had a history of asthma which was usually
well controlled with inhalers and had never previously required a hospital attendance.
There was no other history of note and she denied ever being a smoker. She lived at home
with her husband and two children.
On examination, her respiratory rate was 22 breaths per minute. She was afebrile and
normotensive with a regular pulse rate of 88 per minute. Her cardiovascular and abdominal
examinations were normal, but on auscultation of her lungs there was a prolonged
expiratory wheeze with reduced air entry at the left base.
A chest radiograph was performed as part of her initial investigations (Figure)

• What radiological abnormality is present?
• What is the most likely cause considering her history?

This patient has left lower lobe collapse. Depending on the airway obstructed, each lobe
collapses in a characteristic way. This was originally described by Benjamin Felson, a
professor of radiology in the United States in 1973. In the case of the left lower lobe,
when there is proximal occlusion, the lobe collapses posteriorly and medially towards the
spine. Lying behind the heart, it assumes a triangular shape with a straight lateral border
being classically described as a ‘sail sign’ on posterior–anterior (PA) chest radiograph as
shown in Figure
It usually overlies the cardiac shadow and
can be easily missed on poorly windowed or
under-penetrated films. The collapsed lobe
obscures the left medial hemidiaphragm
and the horizontal fissure swings downwards
with the hilar displaced inferiorly.
Other features to help confirm the diagnosis
would include mediastinal and tracheal
shift towards the side of the collapse, and
possible herniation of the contralateral
lung across the midline from compensatory
hyperinflation. The degree of hilar depression
and compensatory hyperaeration is
variable depending on the degree of collapse.
Less commonly, a stenosing bronchogenic
tumour may be seen as a soft tissue
density overlying the left hilar point.
The causes of lobar collapse are numerous; incidence varies with age and clinical history.
Overall, the commonest cause of collapse is related to a proximal stenosing bronchogenic
carcinoma, and although the majority of lung cancer is seen in men, the incidence in
women is rising. Lung cancer is rarely diagnosed in people younger than 40, but the
incidence rises steeply thereafter with most cases (85 per cent) occurring in people over
the age of 60 with a past medical history of smoking. In ventilated patients, including
neonates, malpositioning of the endotracheal tube can aerate one lung and occlude the
contralateral side, while in infants, collapse related to an inhaled foreign body (e.g. a
peanut) should always be considered. In older children and young adults, the commonest
cause of lobar collapse is as a complication of asthma.

Asthma is a chronic inflammatory disease characterized by reversible airflow limitation
and airway hyperresponsiveness. In response to immunological stimuli, mucus hypersecretion
from goblet cell hyperplasia can cause airway plugging. Proximal occlusion of
a bronchus causes loss of aeration, and as the residual air is gradually absorbed, the lung
volume reduces with eventual collapse. Considering the patient’s age and clinical history,
this is the most likely cause of her left lower lobe collapse.

Wednesday, November 26, 2014

You are asked to review a 72-year-old man on the post-take ward round

You are asked to review a 72-year-old man on the post-take ward round. He was admitted
last night with increasing shortness of breath. His breathing has been getting worse
for many years now, and he notices that it is especially bad in the winter. His general
practitioner (GP) has diagnosed asthma and has been managing him at home. He recalls
having several courses of antibiotics over the last few years.

His recent problems started 3 days ago with a cough productive of green sputum. He has
felt generally unwell and his breathing has deteriorated significantly. He cannot climb
the stairs at home now and slept on the sofa last night. His GP saw him this morning and
referred him to hospital as an infective exacerbation of asthma. He continues to smoke
despite advice, and has a 50 pack-year history. There is no other relevant past medical
history. He takes a salbutamol inhaler when needed but today this was of little help.

Some blood tests were performed and a chest radiograph was requested (Figur). His
white cell count is 16.3 × 109/L, neutrophil count 89 per cent and haemoglobin 14.2 g/dL.

• What does this radiograph show?
• What is the likely diagnosis and how can this be confirmed?

This is a posterior–anterior (PA) chest radiograph of an adult male. The lungs are hyperexpanded
as evidenced by visualizing more than six anterior ribs above the diaphragm.
The distance between the apex of the hemidiaphragm and a line drawn from the costophrenic
to the cardiophrenic angle is less than 1.5 cm, in keeping with diaphragmatic
flattening. The lung parenchyma demonstrates bullous emphysematous disease, most
marked in the upper zones. There is no evidence of consolidation, collapse or pneumothorax.
The cardiomediastinal borders are within normal limits, and both hila are of
normal morphology. This chest radiograph suggests a diagnosis of chronic obstructive
pulmonary disease (COPD).

COPD is a combination of increased mucus production, small airway obstruction and
emphysematous change, with a slow and progressive history of increasing shortness
of breath, usually in association with significant tobacco usage. Most commonly, the
emphysematous component is ‘centrilobular’, with irreversible destruction of normal lung
most in the apical segments of the upper lobes. On computed tomography (CT) this is
clearly seen as central black holes of destroyed lung ‘punched-out’ from normal parenchymal
architecture (Figure 1.2), although a CT is not a necessary investigation in most
cases of COPD. Sometimes the clinical symptoms of COPD are confused with asthma,
which usually starts in childhood and shows greater reversibility of airflow obstruction.
Some patients develop asthma later in life, and in practice both conditions may coexist
or be difficult to differentiate.

• Flattening of the diaphragms and lung hyperexpansion are characteristic chest
radiograph features of COPD.
• COPD is a combination of increased mucus production, small airways obstruction and
emphysematous change.
• Lung function tests are the most important investigation in a patient with COPD.

Tuesday, November 25, 2014

Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?

Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?

A. Amoxicillin
B. Aspirin
C. Atorvastatin
D. Prevacid
E. Sildenafil

The answer is C.  Grapefruit juice inhibits CYP3A4 in the liver, particularly at
high doses. This can cause decreased drug elimination via hepatic metabolism and increase
potential drug toxicities. Atorvastatin is metabolized via this pathway. Drugs that may enhance atorvastatin toxicity via this mechanism include phenytoin, ritonavir, clarithromycin,
and azole antifungals. Aspirin is cleared via renal mechanisms. Prevacid can cause
impaired absorption of other drugs via its effect on gastric pH. Sildenafil is a phosphodiesterase
inhibitor that may enhance the effect of nitrate medications and cause hypotension.

Acute tension pneumothorax is commonly associated with:

Acute tension pneumothorax is commonly associated with:

a. Facial flushing.
b. Hypotension and vagally mediated bradycardia.
c. Ventricular fibrillation-induced cardiac arrest.
d. Right axis deviation on electrocardiogram.
e. Hyperresonance to percussion on the affected side.

The answer is e. Tension pneumothorax is characterized by dyspnea, hypotension, decreased venous return to the heart, midline shift of the trachea and mediastinal structures away from the side of tension, a hyperresonant ercussion note, and tachycardia. Untreated tension pneumothorax can quickly deteriorate to cardiac arrest andpulseless electrical activity. Although sometimes clinically indistinguishable from tamponade, a tensionpneumothorax is the more common occurrence and a clinical diagnosis is usually possible. Treatment is needledecompression followed by tube thoracostomy.

Sunday, November 23, 2014

A 7-year-old girl has palpable purpura and petechiae on her legs and buttocks

A 7-year-old girl has palpable purpura and petechiae on her legs and buttocks and is complaining of
abdominal pain. You know that:

a. The most common presentation also includes arthralgias and microscopic hematuria.
b. This is a hypersensitivity vasculitis with immune complex deposition affecting the blood vessels, especially the veins, exclusively of the lower extremities.
c. An indolent form of meningococcemia may mimic this condition.
d. The condition lasts for approximately 2 weeks.
e. All patients with this condition should be hospitalized for further management.

The answer is a. Henoch-Sch¨onlein purpura is a systemic vasculitis usually seen in children between the ages of 4 and 11 years. There is immune complex deposition of immunoglobulin A in the arterioles and capillaries anywherein the body. Patients usually have abdominal complaints in 70% of cases. The classic presentation is that of a child with abdominal pain, arthralgias, microscopic hematuria, and the characteristic palpable purpuric and petechial rash in the lower extremities and buttocks. A child with meningococcemia may present similarly, although with
more toxicity and abruptness of symptoms. Criteria for admission include severe abdominal pain, severe arthralgias, uncertain diagnosis, or inability to exclude meningococcemia, and intractable vomiting. Steroids are reserved for patients with severe abdominal pain, hematuria, and disabling arthralgias. The course remits and relapses over a course of several weeks to months.



Leprosy is a chronic granulomatous infection of humans that primarily affects the skin and peripheral nerves.

● Skin lesion: most common initial presentation
● Sensory loss
● Anhidrosis
● Neuritic pain
● Palpable peripheral nerves
● Nerve damage (most commonly affected nerves are ulnar, median, common peroneal, posterior tibial, radial cutaneous nerve of the wrist, facial, and posterior auricular)
● Muscle atrophy and weakness
● Foot drop
● Claw hand and claw toes
● Lagophthalmos, nasal septal perforation, collapse of bridge of nose, loss of eyebrows resulting in “leonine” facies (Fig.)

Leprosy can present along a spectrum from simple cutaneous skin lesions with minimal sensory loss to severe extensive skin involvement, painful neuritis, muscle wasting and contractures, and multiple peripheral nerve damage.

● Leprosy is caused by Mycobacterium leprae, an obligate intracellular acid-fast rod.
● The mode of transmission remains elusive. Spread in humans is thought to occur via the respiratory route or entry through broken skin.
● Zoonotic transmission from armadillos has not been proved.
● The majority of people exposed to patients with leprosy do not develop the disease because of their natural immunity.
● Incubation period is 3 to 5 years.

● The diagnosis of leprosy relies on a detailed history and physical examination and is established by the demonstration of acid-fast bacilli in skin smears or skin biopsies of the affected sites.
● Leprosy has been classifi ed according to the World Health

Organization (WHO) system into:
1. Paucibacillary leprosy defi ned as fewer than fi ve skin lesions with no bacilli on skin smear
2. Multibacillary leprosy defi ned as six or more skin lesions and may be skin-smear positive

● Leprosy has also been classifi ed more specifi cally according to the type of skin lesions, sensory and motor defi cits, and biopsy into:

1. Indeterminate leprosy
2. Tuberculoid leprosy (paucibacillary [few organisms], intense infl ammatory reaction; few, welldemarcated skin lesions)
3. Borderline tuberculoid leprosy
4. Borderline lepromatous leprosy
5. Lepromatous leprosy  (multibacillary [numerous organisms], inadequate host response; diffuse,
poorly organized skin lesions)

Thursday, November 20, 2014



Facial spasm and risus sardonicus 

Tetanus is a life-threatening illness manifested by muscle rigidity and spasms; it is caused by a neurotoxin (tetanospasmin) produced by Clostridium tetani.

● Trismus (“lockjaw”)
● Risus sardonicus (“peculiar grin”), characteristic grimace that results from contraction of the facial muscles (Fig.)
● Generalized muscle spasms causing severe pain and, at times, respiratory compromise and death
● Rigid abdominal muscles, fl exed arms, and extended legs
● Autonomic dysfunction several days after onset of illness
● Leading cause of death: fl uctuations in heart rate and blood pressure
● Usually, absence of fever
● Localized tetanus

1. Rigidity of muscles near the injury
2. Weakness as a result of lower motor neuron injury
3. May be self-limited and resolve spontaneously
4. More often progresses to generalized tetanus
5. Cephalic tetanus:
a. May occur with head injuries or chronic otitis with localized ear or mastoid infection with C. tetani
b. Can manifest as cranial nerve dysfunction

● C. tetani is a gram-positive, spore-forming bacillus that resides primarily in the soil.
● Majority of cases are caused by punctures and lacerations.
● Toxin is elaborated from organisms in a contaminated wound.
● Local symptoms are caused by inhibition of neurotransmitter at presynaptic sites.

1. Over the next 2 to 14 days, the toxin travels up the neurons to the CNS, where it acts on inhibitory neurons to prevent neurotransmitter release.
2. Unopposed motor activity results in tonic contractions of muscles.

● Strychnine poisoning
● Dystonic reaction caused by neuroleptic agents
● Local infection (dental or masseter muscle) causing trismus
● Severe hypocalcemia
● Hysteria

● Positive wound culture is not helpful in diagnosis.
● Isolation of organism is possible in patients without the illness.

● Usually, normal blood counts and chemistries
● Toxicology of serum and urine to rule out strychnine poisoning

● Monitoring in a hospital ICU: keep surroundings dark and quiet
● Intubation or tracheostomy for severe laryngospasm
● Débridement of wound
● Human tetanus immunoglobulin (HTIg) via IM injection
● Tetanus toxoid (Td) by IM injection at a different site
● Metronidazole or penicillin G IV
● IV diazepam to control muscle spasms
● Neuromuscular blockade if necessary

D. Pronator drift

During a neurologic examination, you ask a patient to stand with both arms fully extended and parallel to the ground with his eyes closed for 10 seconds.

What is the name of this test?
A. Babinski sign
B. Dysdiadochokinesis
C. Lhermitte symptom
D. Pronator drift
E. Romberg sign

The answers is D: The ability to perform a thorough

neurologic examination is an important skill for all internists to master. A careful
neurologic examination can localize the site of the lesion and is important in directing
further workup. The components of the neurologic examination include mental status,
cranial nerves, motor, sensory, gait, and coordination. The motor examination is further
characterized by appearance, tone, strength, and reflexes. Pronator drift is a useful tool for
determining if upper extremity weakness is present. In this test, an individual is asked to
stand with both arms fully extended and parallel to the floor while closing his or her eyes. If
the arms flex at the elbows or fingers or there is pronation of the forearm, this is considered
a positive test. Other tests of motor strength include tests of maximal effort in a specific
muscle or muscle group. Most commonly this type of strength testing is graded from 0 (no
to 5 (full power) with varying degrees of weakness noted against resistance.
However, many individuals find it more practical to use qualitative grading of strength,
such as paralysis, severe weakness, moderate weakness, mild weakness, or full strength.
Babinski sign is a sign of upper motor neuron disease above the level of the S1 vertebra
and is characterized by paradoxical extension of the great toe with fanning and extension
of the other toes as well. Dysdiadochokinesis refers to the inability to perform rapid alternating
movements and is a sign of cerebellar disease. Lhermitte symptom causes electric
shock–like sensations in the extremities associated with neck flexion. It has many causes
including cervical spondylosis and multiple sclerosis. Romberg sign is performed with an
individual standing with feet together and arms at the side. The individual is then asked
to close his or her eyes. If the individual begins to sway or fall, this is considered a positive
test and is a sign of abnormal proprioception.

Wednesday, November 19, 2014

Subconjunctival hemorrhages and jaundice in leptospirosis.

Leptospirosis (Weil’s disease) is a zoonosis caused by the spirochete Leptospira interrogans.


● Milder and more common presentation of disease

● A self-limited systemic illness with two stages:
1. Septicemic stage: presents abruptly with fevers, headache, severe myalgias, rigors, prostration, and sometimes circulatory collapse; conjunctival suffusion is common; skin rash, pharyngitis, lymphadenopathy, hepatomegaly, splenomegaly.

2. Immune stage: occurs a few days after fi rst stage with similar symptoms; hallmark is aseptic meningitis.

1. Denotes severe cases, with symptoms of hepatic, renal, and vascular dysfunction

2. Biphasic course: persistence of fever, subconjunctival hemorrhages, jaundice (Fig. ), and azotemia
3. Complications: oliguria or anuria, hemorrhage, hypotension,
vascular collapse

Caused by a spirochete, L. interrogans
● Infects a variety of animals, including most mammals
● Specifi c serotypes associated with different hosts—pomona in livestock, canicola in dogs, and icterohaemorrhagiae in rodents
● Exposure to animal urine or infected water method by which organism penetrates skin or mucous membranes

● Bacterial meningitis
● Viral hepatitis
● Infl uenza
● Legionnaire’s disease

Cultures of blood, CSF, and urine:
● Organism can be isolated from blood or CSF during fi rst 10 days of illness.
● Urine should be cultured after fi rst week and for up to 30 days after onset of illness.

● Normal or elevated WBCs, at times up to 70,000/mm3
● Elevated transaminases or bilirubin
● Anemia, azotemia, hypoprothrombinemia in those with icteric illness
● Elevated CK in fi rst phase
● Meningitis in both phases, but aseptic in second phase

Chest radiographs to show bilateral nonlobar infi ltrates

● IV penicillin G
● Doxycycline
● Vitamin K administration if hypoprothrombinemia present