Mucormycosis Superinfection of a Chemical Burn.

Mucormycosis is an uncommon infection but is increasing in prevalence. Cutaneous disease is associated with burns and traumatic injuries. Cutaneous mucormycosis is the least deadly form but mortality is still approximately 36%. Burn superinfection with mucormycosis is increasingly common and can be an insidious process which may not present until disease disseminates. We present the case of a 30-year-old male who presented to the Emergency Department for rash. A rash with yellow crusting was noted to involve his scalp, face, ear, R shoulder, and parts of both feet. He had been placed on antibiotics by an urgent care a few days prior to presenting. He denied systemic symptoms, chemical exposure, change in detergent, auto-immune diseases, or travel. Patient has a history of intravenous opioid and dissociative abuse and had multiple episodes of syncope- including at his work in a factory where there were hot metals, refrigerants, and numerous corrosive chemicals. Surgical debridement revealed mucormycosis on pathology. Patient was treated with isavuconazole, surgical debridement and skin grafting. He experienced complete recovery.

Validation of Methicillin-Resistant Staphylococcus aureus (MRSA) Risk Factors in Predicting MRSA Community-Acquired Pneumonia at an Academic Medical Center.

Background: The 2019 Infectious Diseases Society of America community-acquired pneumonia (CAP) guidelines recommend antimethicillin- resistant Staphylococcus aureus (MRSA) therapy in patients with CAP based on previously identified risk factors for MRSA with an emphasis on local epidemiology and institutional validation of risk. Thus, we sought to assess the ability of guideline-recognized risk factors to predict MRSA CAP at our institution. Methods: This was a single-center, retrospective cohort study from January 2016 to March 2020. Patients were included if they were >18 years old, diagnosed with CAP, and had a MRSA nasal screen and respiratory culture obtained on admission. Patients were excluded if CAP diagnosis was not met, respiratory cultures were not obtained within 48 hours of antibiotic initiation, or they had cystic fibrosis. Sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios (LR) were calculated using Vasser Stats 2019. Pre/post-test odds and pre/post-test probabilities were calculated using Excel 2019. Results: Of 705 screened patients, 221 were included. MRSA prevalence in CAP patients at our institution was 3.6%. History of MRSA isolated from a respiratory specimen had high specificity (98%), high positive LR of 20 (95% CI 5.3-74.8), and high post-test probability of 42.8%. Receipt of IV antibiotics during hospitalization within the past 90 days had a positive LR of 1.9 (95% CI 0.74-4.84). A positive MRSA nasal screen on admission had a positive LR of 6.9 (95% CI 4.0-12.1), negative LR 0.28 (95% CI 0.08-0.93), positive post-test probability of 20.7%, and negative post-test probability of 1.04%. Conclusion: Our study utilized institutional data to validate guideline recognized risk factors for MRSA CAP specifically at our institution. Risk factors including history of MRSA isolated from a respiratory specimen, and positive post-admission MRSA nasal screen were validated as significant risk factors; receipt of IV antibiotics during hospitalization within the past 90 days was not shown to be a risk factor for MRSA CAP based on our institutional data. Validated risk factors may help providers discern which patients with CAP at our institution would benefit most from empiric MRSA treatment.

High-Fidelity Simulation Scenario: Pediatric Sulfonylurea Overdose and Treatment.

Introduction: Oral antidiabetic medications are becoming increasingly popular as the incidence of type II diabetes mellitus increases. Overdoses of these medications, either intentional or accidental, can be detrimental if not quickly recognized and treated. One of the most common classes of hypoglycemic oral antidiabetics, sulfonylureas, was discussed in this case. Methods: We designed this high-fidelity simulation to help increase the learner's knowledge of sulfonylurea overdoses, including recognizing signs/symptoms, management, and disposition. This simulation was designed to be used with fourth-year medical students, emergency medicine residents, and pediatric residents. The case involves a previously healthy 3-year-old male presenting with altered mental status and seizures secondary to glyburide ingestion. A standard pediatric simulation mannequin was required. The patient presented with altered mental status and began seizing upon arrival. After a thorough history, glyburide ingestion was identified. Critical actions included obtaining a fingerstick glucose measurement, determining an appropriate concentration of dextrose, starting a dextrose drip, and admission for further management. Results: This simulation case was performed at the simulation lab at SUNY Upstate Medical University by a combination of 83 fourth-year medical students, and emergency medicine and pediatric residents. Feedback and evaluations for the case showed it improved medical education and clinical skills. Discussion: This simulation was well received and helped participants develop a better understanding of sulfonylurea overdose identification. It also improved participants' ability to manage refractory hypoglycemia and compile a more comprehensive list of differential diagnoses.

Points & Pearls: Blunt cardiac injury: emergency department diagnosis and management

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies. [Points & Pearls is a digest of Emergency Medicine Practice.]

Blunt cardiac injury: emergency department diagnosis and management.

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

Physicians' understanding of CT probabilities in ED patients with acute abdominal pain.

OBJECTIVE: Computerized tomography (CT) is often employed to diagnose or rule out certain suspected abdominal pathologies. The aim of this study is to compare emergency physicians' estimated post-test disease probabilities to the probabilities obtained for similar diagnostic tests as reported in the literature. METHODS: Physicians were asked to estimate pre and posttest probabilities before and after CT scan results in patients with nontraumatic abdominal and pelvic pain. The actual post-test probability was calculated using published likelihood ratios and compared to physician judgment. RESULTS: 210 patient encounters were included. In the negative CT group, physicians' median pre-test probability was 40% with a post-test probability of 0%, while the actual post-test probability is 4.2% (p<0.001). Physicians' median pre-test probability for a positive CT was 70% with a post-test probability of 100%, while the actual post-test probability is 98% (p<0.001). The diverticulitis subgroup had no significant differences between physician and actual post-test probabilities. The post-op abscess subgroup had significant differences in post-test probabilities in both the negative CT (30% difference, p=0.028) and positive CT subgroups (-37% difference, p=0.003). CONCLUSIONS: When applying the probability theory of disease, physicians tend to overestimate the power of CT scanning. The difference in physician and actual post-test probabilities may be small or not clinically significant in diseases with good positive and negative likelihood ratios such as in diverticulitis; however, this difference may be large and clinically significant in diseases with poor likelihood ratios such as in post-op abscess.

Adherence to head computed tomography guidelines for mild traumatic brain injury.

INTRODUCTION: Traumatic brain injury (TBI) is a significant health concern. While 70-90% of TBI cases are considered mild, decision-making regarding imaging can be difficult. This survey aimed to assess whether clinicians' decision-making was consistent with the most recent American College of Emergency Physicians (ACEP) clinical recommendations regarding indications for a non-contrast head computed tomography (CT) in patients with mild TBI. METHODS: We surveyed 2 academic emergency medicine departments. Six realistic clinical vignettes were created. The survey software randomly varied 2 factors: age (30, 59, or 61 years old) and presence or absence of visible trauma above the clavicles. A single important question was asked: "Would you perform a non-contrast head CT on this patient?" RESULTS: Physician decision-making was consistent with the guidelines in only 62.8% of total vignettes. By age group (30, 59, and 61), decision-making was consistent with the guidelines in 66.7%, 47.4%, and 72.7% of cases, respectively. This was a statistically-significant difference when comparing the 59- and 61-year-old age groups. In the setting of presence/absence of trauma above the clavicles, respondents were consistent with the guidelines in 57.1% of cases. Decision-making consistent with the guidelines was significantly better in the absence of trauma above the clavicles. CONCLUSION: Respondents poorly differentiated the "older" patients from one another, suggesting that respondents either inappropriately apply the guidelines or are unaware of the recommendations in this setting. No particular cause for inconsistency could be determined, and respondents similarly under-scanned and over-scanned in incorrect vignettes. Improved dissemination of the ACEP clinical policy and recommendations is a potential solution to this problem.

Blood culture results do not affect treatment in complicated cellulitis.

BACKGROUND: Cellulitis, a frequently encountered complaint in the Emergency Department, is typically managed with antibiotics. There is some debate as to whether obtaining blood cultures and knowing their results would change the management of cellulitis, although most authors argue that information from blood cultures does not change the empirical management of uncomplicated cellulitis. However, for complicated cellulitis (as defined by the presence of significant comorbidity), there is considerable disagreement and lack of evidence as to the utility of blood cultures. OBJECTIVE: Our aim was to determine the role of blood cultures in the management of complicated cellulitis. METHODS: This retrospective chart review assessed the utility of obtaining blood cultures in complicated cellulitis (as defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of individuals without medical comorbidity. RESULTS: Six hundred and thirty-nine patients were identified, 314 of which were deemed cases and 325 controls. Within the cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95% confidence interval 0.99-3.43). A clinically significant change in management (a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325 controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval 0.434-5.5541). CONCLUSIONS: Within this cohort of patients with complicated cellulitis, blood cultures rarely changed management from empirical coverage.

Spontaneous showering of tumor emboli in a patient with advanced primary lung cancer: a case report.

Extension of primary lung tumors into the left atrium via pulmonary veins is a well-documented phenomenon. Peripheral arterial embolism and cerebral embolism originating from a primary lung neoplasm are rare events. We report a case of simultaneous acute bilateral lower limb ischemia, bilateral renal infarction, splenic infarction and cerebral infarction as a result of multiple emboli originating from primary lung malignancy invasion of the left atrium. An emergent embolectomy revealed pathologic features of the extracted thrombus that were identical to the pulmonary neoplasm.

Rates of positive blood, urine, and cerebrospinal fluid cultures in children younger than 60 days during the vaccination era.

BACKGROUND: Fever is a common reason children present to the emergency department. The goal of this study was to determine the rates and the etiology of bacterial infection in children younger than 2 months during the vaccination era. METHODS: This is a retrospective chart review performed at a tertiary care hospital. Electronic medical records were used to identify patients who had a workup for fever/sepsis in the emergency department. The search was limited to identifying only children younger than 60 days. RESULTS: A total of 207 patients satisfied the inclusion/exclusion criteria. In children younger than 28 days, the blood culture-positive rate was 2.7% (range, 0.0%-6.4%), the urine culture-positive rate was 10.7% (range, 3.5%-17.8%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 0% (range, 0.0%-3.9%). In children 29 to 60 days, the blood culture-positive rate was 1.5% (range, 0.0%-3.6%), urine culture-positive rate was 8.5% (range, 3.7%-13.3%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 1.7% (range, 0.0%-5.0%). Urinary tract infections due to Escherichia coli were very common, whereas no cases of Haemophilus influenzae and one case of Streptococcus pneumoniae were detected. CONCLUSIONS: Urinary tract infections due to E. coli are very common in this age group. The classic pathogens H. influenzae and S. pneumoniae were essentially nonexistent in this study possibly because of herd immunity obtained through current vaccination practices.

Effects of disrupting the polyketide synthase gene WdPKS1 in Wangiella [Exophiala] dermatitidis on melanin production and resistance to killing by antifungal compounds, enzymatic degradation, and extremes in temperature.

BACKGROUND: Wangiella dermatitidis is a human pathogenic fungus that is an etiologic agent of phaeohyphomycosis. W. dermatitidis produces a black pigment that has been identified as a dihydroxynaphthalene melanin and the production of this pigment is associated with its virulence. Cell wall pigmentation in W. dermatitidis depends on the WdPKS1 gene, which encodes a polyketide synthase required for generating the key precursor for dihydroxynaphthalene melanin biosynthesis. RESULTS: We analyzed the effects of disrupting WdPKS1 on dihydroxynaphthalene melanin production and resistance to antifungal compounds. Transmission electron microscopy revealed that wdpks1Delta-1 yeast had thinner cell walls that lacked an electron-opaque layer compared to wild-type cells. However, digestion of the wdpks1Delta-1 yeast revealed small black particles that were consistent with a melanin-like compound, because they were acid-resistant, reacted with melanin-binding antibody, and demonstrated a free radical signature by electron spin resonance analysis. Despite lacking the WdPKS1 gene, the mutant yeast were capable of catalyzing the formation of melanin from L-3,4-dihyroxyphenylalanine. The wdpks1Delta-1 cells were significantly more susceptible to killing by voriconazole, amphotericin B, NP-1 [a microbicidal peptide], heat and cold, and lysing enzymes than the heavily melanized parental or complemented strains. CONCLUSION: In summary, W. dermatitidis makes WdPKS-dependent and -independent melanins, and the WdPKS1-dependent deposition of melanin in the cell wall confers protection against antifungal agents and environmental stresses. The biological role of the WdPKS-independent melanin remains unclear.

Adrenal infections.

Adrenal infections are an important but under-recognized clinical entity. The adrenal gland can be infected by a myriad of pathogens including fungi, viruses, parasites, and bacteria. Infection can directly or indirectly cause tissue damage and alteration in endocrine function. Direct damage occurs via microbial replication and local production of toxic compounds, such as endotoxins. Indirect damage results from alterations in the regulation of a host's immunologic and endocrine mediators in response to damage by a microbe at a distant site. Variations in pathogen tropism, adrenal anatomy, and host immune integrity contribute to the progression of active disease and discernable adrenal dysfunction. Early recognition and intervention in the case of adrenal infection can significantly improve outcome, demonstrating the need for increased clinical suspicion in the appropriate clinical setting.

Tuberculosis in New York city: recent lessons and a look ahead.

In the late 1980s and early 1990s, after decades of decline, the incidence of tuberculosis began to rise in New York city, reaching a peak of 3811 cases by 1992. The epidemic took root in a setting of inadequate treatment regimens, homelessness, a diminished public-health system, and the onset of the HIV/AIDS epidemic. In addition, a subepidemic of drug-resistant tuberculosis occurred throughout New York city, most notably in a series of well documented nosocomial outbreaks. By 1994, using broadened initial treatment regimens, directly observed therapy, and improved US Centers for Disease Control and Prevention guidelines for hospital control and disease prevention, New York city began to effectively halt the progression of the epidemic. By 2002, tuberculosis rates in New York city reached an historic low of 1084. However, given the presence of a large reservoir of latently infected individuals in the city and an ongoing tuberculosis pandemic, New York city continues to face significant challenges from this persistent pathogen.