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A (Acute viral parotitis)
(Parotitis refers to inflamed parotid glands which are exocrine glands that produce saliva. When inflamed, these glands become swollen and painful, and the superficial skin becomes erythematous. Parotitis can present unilaterally or bilaterally. It has various etiologies including bacterial and viral causes, and commonly the mumps virus)
(This patient is experiencing parotitis, or inflammation of the parotid glands. These glands are within the mouth on both sides, sitting deep and just anterior to the ears. They are responsible for saliva production, and thus when they cannot function properly they result in a dry mouth. Parotitis has various etiologies, and the most common in children is the mumps virus, which is the most likely cause of this patient's symptoms. Mumps mostly affects children and causes parotitis among other viral symptoms. It typically affects the parotid glands but can also affect the submandibular glands as well. There is a vaccine to prevent mumps, and since this patient has not had updated immunizations, her symptoms should give a clue towards this diagnosis. Inflamed parotid glands are often presented in mumps along with systemic symptoms such as a fever and malaise) D (Intranasal glucocorticoids)
(Althought there are many options for the treatment of allergic rhinitis, topical (spray) intranasal corticosteroids are the most effective management option)
(Allergic rhinitis is characterized by allergy-type symptoms most often involving rhinorrhea, sneezing, problems with smell, and itching affecting the nose, mouth, eyes, throat, and skin. It is triggered by an allergen such as pollen, mold, dust, or pet dander. This boy's allergies apparently have a seasonal onset - common in allergic rhinitis, and the reason why a subset is also called seasonal allergic rhinitis)
(The most effective treatment is to avoid trigger environments; however, medications can be very effective depending on the severity of the symptoms. Antihistamines are effective for short-term relief. Topical intranasal corticosteroids are currently known to be the most effective way to manage moderate allergic rhinitis, and they have a better safety profile compared to oral corticosteroids (i.e. fewer systemic adverse effects). Other treatment options include decongestants, nasal washes, leukotriene inhibitors, and (if symptoms are unremitting/refractory) immunotherapy) E (Piperacilin-tazobactam)
(Otitis externa, or outer ear infections, are commonly caused by Pseudomonas aeruginosa, a gram-negative aerobic bacilli that is resistant to many antibiotics and is a common source of nosocomial infections. It is often treated with the combination antibiotic Piperacillin/tazobactam)
)Pseudomonas aeruginosa is the most common cause of otitis externa and is a gram-negative aerobic bacilli that can cause severe nosocomial, or hospital acquired, infections due to the fact that it is resistant to many antibiotics and is associated with a high mortality. It rarely causes disease in healthy people. Patients who are more susceptible to infection with P. aeruginosa include patients with skin barrier disruption (burn injuries, intravenous lines, urinary/dialysis catheters, endotracheal tubes) and immunocompromised patients. Important considerations when treating P. aeruginosa infection include antibiotic resistance, prompt combination therapy in high risk patients, and source control)
(Piperacillin/tazobactam is a combination antibiotic that is commonly used to treat many Gram-positive and Gram-negative bacteria, including P. aeruginosa infections. It is comprised of an extended-spectrum penicillin antibiotic (piperacillin) as well as a β-lactamase inhibitor (tazobactam). The most common side effect is diarrhea, with one study showing that Clostridium difficile-associated diarrhea happened in 4.9% of the patients on piperacillin/tazobactam) E (Malignant otitis externa)
(Malignant otitis externa, or necrotizing external otitis, is an uncommon form of otitis that occurs primarily in immunocompromised patients and early diabetic patients, particularly when the diabetes is being poorly managed. It typically begins as a case of acute otitis externa, but can develop into a potentially lethal infection)
(Malignant otitis externa, or necrotizing external otitis, is an uncommon form of otitis that occurs primarily in immunocompromised patients and early diabetic patients, particularly when the diabetes is being poorly managed. It typically begins as a case of acute otitis externa, which is characterized by ear pain, swelling of the ear canal, and occasionally decreased hearing. These infections of the outer ear are most often caused by Pseudomonas aeruginosa and Staphylococcus aureus and can often be treated with antibiotics to kill the organism and corticosteroids to reduce itching and inflammation)
(Unlike acute otitis externa, malignant otitis externa is potentially fatal and commonly presents with severe, deep pain, greenish foul smelling discharge and hearing loss. It is caused by extension of the outer ear infection into the bony ear canal and soft tissues deep to the bony canal and can result in skull base osteomyelitis and multiple cranial nerve palsies. The offending pathogen is almost always Pseudomonas aeruginosa and, unlike acute otitis externa, malignant otitis externa requires oral or intravenous antibiotics) A (Pseudomonas aeruginosa)
(Otitis externa, sometimes referred to as "swimmer's ear," is an inflammation of the outer ear that presents with ear pain, swelling of the ear canal, and loss of hearing. It is most commonly caused by Pseudomonas aeruginosa, a Gram-negative rod that is also responsible for "hot-tub" folliculitis)
(This patient has otitis externa, or outer ear infection, which often presents with ear pain, swelling of the ear canal, and loss of hearing. Otitis externa is sometimes referred to as "swimmer's ear" due to its prevalence among frequent swimmers. In these cases, constant water exposure to the ear canal can reduce the amount of cerumen (earwax) that is present, leading to maceration of the canal. Furthermore, frequent exposure to water can slightly raise the pH, making the canal more favorable for bacterial overgrowth)
(Pseudomonas aeruginosa and Staphylococcus aureus are the two organisms most commonly responsible for otitis externa due to the fact that they both thrive in unclean water. Pseudomonas aeruginosa is a Gram-negative rod that is most frequently responsible for both "swimmer's ear" and pseudomonas folliculitis, which is the rash shared by the patient's other teammates in the vignette.) A 19 year-old college student complains of a sore throat for over a week, with fever and general malaise. On exam T-38°C P-70/minute R-20/minute BP-110/76 mmHg. The patient is alert and oriented x 3. The skin is warm, dry, and without rash. The TMs have a normal light reflex and the canals are clear. The oropharynx is inflamed, with bilaterally enlarged tonsils, and a small amount of exudate. The neck is supple, with anterior cervical adenopathy. The lungs are clear. The heart has a regular rhythm without murmurs. The abdomen is soft, nontender and a spleen tip is palpable. The labs reveal a negative rapid strep screen and positive Monospot. The WBC count is 9,000/microliter with a differential of 40% atypical lymphocytes, 35% lymphocytes, 5% monocytes, 10% eosinophils, and 10% neutrophils. Which of the following is the most appropriate treatment?
A. Penicillin
B. Erythromycin
C. Acetaminophen
D. Acyclovir A (Acute sinusitis)
(Acute sinusitis is characterized by symptoms of less than four weeks duration, nasal congestion, purulent nasal discharge, and maxillary tooth discomfort)
(Acute sinusitis is characterized by symptoms less than four weeks old, nasal congestion and obstruction, purulent nasal discharge, and maxillary tooth discomfort)
(The condition is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin, mostly caused by rhinoviruses, coronaviruses, and influenza viruses)
(Suspect a bacterial sinusitis if symptoms do not improve within 10 days, if a fever greater than 39˚C (102.2˚F) is present, if or symptoms worsen after the patient experiences typical upper respiratory tract infections (e.g. fever, headache, nasal drainage). If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis)
(The proximity of the brain to the sinuses make the most dangerous complications of sinusitis neurological. Abscesses, meningitis, and orbital cellulitis may result) A (Begin amoxicillin-clavulanate)
(Amoxicillin-clavulanate is the recommended first line treating agent (for a 5-7 day course in uncomplicated cases) in treating bacterial rhinosinusitis)
(Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition. Symptoms of acute bacterial rhinosinusitis include the following facial pain or pressure (especially unilateral), hyposmia/anosmia, nasal congestion, nasal drainage postnasal drip, fever, cough, fatigue, maxillary dental pain, and ear fullness/pressure. The diagnosis of acute bacterial sinusitis should be entertained under either of the following circumstances: presence of symptoms or signs of acute rhinosinusitis 10 days or more beyond the onset of upper respiratory symptoms, and worsening of symptoms or signs of acute rhinosinusitis within 10 days after an initial improvement. First-line therapy is amoxicillin with or without clavulanate) B (Orbital cellulitis)
(Acute bacterial rhinosinusitis should be treated with antibiotics because of the severity of potential complications. These include orbital cellulitis, meningitis, osteomyelitis, and local abscesses)
(Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition. Symptoms of acute bacterial rhinosinusitis include the following facial pain or pressure (especially unilateral), hyposmia/anosmia, nasal congestion, nasal drainage postnasal drip, fever, cough, fatigue, maxillary dental pain, and ear fullness/pressure. The diagnosis of acute bacterial sinusitis should be entertained under either of the following circumstances: presence of symptoms or signs of acute rhinosinusitis 10 days or more beyond the onset of upper respiratory symptoms, and worsening of symptoms or signs of acute rhinosinusitis within 10 days after an initial improvement)
(The most common cause of orbital cellulitis is acute bacterial rhinosinusitis (ABRS). The other choices listed are not associated with rhinosinusitis. ABRS should be treated to avoid other complications aside from orbital cellulitis such as meningitis, osteomyelitis of facial bones, or abscesses within the brain or meninges) C (Sensorineural hearing loss)
(Tinnitus is a common condition that is characterized by a ringing, roaring, rushing, buzzing, or whistling sound in the ears. The condition may be continuous or pulsatile with each heartbeat. In most cases, there is an associated hearing loss. In fact, the major cause of tinnitus is a sensorineural hearing loss. The list of associated conditions is extensive and includes obstruction of the canals, eustachian tube dysfunction, otosclerosis, Meniere's disease, aminoglycoside toxicity, chronic use of salicylates, anemia, hypertension, hypothyroidism, hyperlipidemia, noise-induced hearing loss, and tumors associated with the inner ear (e.g., acoustic neuroma). The evaluation of a patient with tinnitus includes an audiogram and CT scan or MRI of the head, with special emphasis given to the temporal area. Pulsatile tinnitus may require vascular studies to rule out aneurysm formation. Treatment depends on the diagnosis, but in most cases if the underlying disease is controlled, the tinnitus disappears. If no underlying disease process is present, background music or amplification may help to relieve symptoms) 