WikEM - User contributions [en]

Typhoid fever

2014-08-12T16:00:58Z

Cathylewwho:

==Background==
*Diagnosed in 2% of febrile travelers and caused by ''[[Salmonella]] enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''
*Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent
*Prior vaccination does not exclude infection
*Incubation period 1-3 weeks with chronic carrier state defined as organism in urine or stool > 12 months
*Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms==
===Classic symptoms===
*[[Bradycardia]] relative to fever

===Initial symptoms===
*[[Fever]]
*[[Abdominal Pain]]
*[[Headache]]

===Subsequent symptoms===
*Chills (rarely rigors)
*Cough
*Abdominal distension
*Constipation (more common than diarrhea)
*“Rose spots” – truncal light red macular rash (in the 2nd wk)
*Hepatosplenomegaly
*GI bleeding
*Transaminitis
*Leukopenia with left shift (adults)
*Leukocytosis (children)

==Diagnosis and Work-Up==
*Blood culture
*Urine culture
*Stool culture
*“Rose spot” aspiration
*Bone marrow culture (most sensitive)
*Sensitivity testing for nalidixic acid

==Complications==
*Small-bowel ulceration
*Intestinal perforation
*[[Anemia]]
*[[DIC]]
*[[Pneumonia]]
*[[Meningitis]]
*[[Myocarditis]]
*[[Cholecystitis]]
*[[Renal Failure]]
*Chronic carrier state

==Differential Diagnosis==
*[[Malaria]]
*[[Typhus]]
*Viral hepatitis
*Amebic Liver Abscess
*Infectious enteritis

==Treatment==
*Consultation with Infectious Disease should be considered since there are increasingly multidrug resistant strains of S. Typhi and coinfection with diseases such as [[Malaria]] may complicate treatment. The therapy favors the use of fluorquinolones unless suspected or known resistance.<ref>Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489205/pdf/bmj33300078.pdf PDF]</ref>
===Antibiotics===
{{Typhoid Antibiotics}}

===Adjunctive Therapy===
*If associated delirium, coma, shock, and/or [[DIC]]: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition==
*Admit if any complication

==Sources==
<references/>
*Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.
*Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Hydrogen sulfide toxicity

2014-08-12T14:52:25Z

Cathylewwho:

Hydrogen Sulfide Poisoning. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==General Information:==

Colorless, flammable gas

Encountered in following industries: oil, gas, organic decomposition (sewer and manure), roofing asphalt tanks

Most common fatal gas exposure

“Rotten egg” smell which diminishes with high concentrations or prolonged low concentration exposure

Often used in suicide attempts: acidic detergent (toilet bowl cleaner) is mixed with bath salts or pesticides

==Mechanisms of toxicity:==

*Highly lipid soluble

*Disrupts oxidative phosphorylation by inhibiting cytochrome oxidase aa3 (toxicity through cellular asphyxia and impairs ATP production) => lactate accumulation and metabolic acidosis

*Causes hyperpolarization of potassium-mediated channels in neurons

*Potentiates neuronal inhibitory mechanisms

*Alters brain neurotransmitter content and release

==Symptoms:==

*Respiratory: dyspnea, cyanosis, hemoptysis, rales, delayed pulmonary edema

*Ophthalmic: conjunctivitis, corneal ulceration, corneal scarring

*Central nervous system: headache, weakness, disequilibrium, intention tremor, muscle rigidity, loss of consciousness, seizures, coma

*Gastrointestinal: green-gray line on gingiva, nausea, vomiting

*Cardiovascular: chest pain, bradycardia

*Neuropsychiatric: amnesia, lack of insight, disorientation, delirium, dementia
*Death

==Differential Diagnosis:==

Carbon Monoxide Toxicity

Cyanide Toxicity

Hydrocarbon Toxicity

Smoke Inhalation Injury

==Diagnosis:==

*No single test to verify exposure or levels

*ABG: metabolic acidosis and normal oxygen saturation (unless pulmonary edema present)

*Elevated lactate

*Discolored copper coins found on patient may be helpful in diagnosis

==Treatment:==

*Removal from source

*100% oxygen

*Can give nitrite component of cyanide antidote kit (do NOT give the thiosulfate portion):
**Theoretically increasing methemoglobin formation in blood will cause conversion of sulfide to sulfmethemoglonin (less toxic)
**Sodium nitrite (3% NaNO2) IV over 2-4 minutes
**Adult dose: 10 mL
**Obtain methemoglobin level 30 minutes after dose (desired level < 30%)

*Hyperbaric oxygen therapy (though not proven to have any benefit)

==Disposition:==

*Admission, likely to MICU

*Toxicology consult

==Sources:==

Tintinalli et. al. Hydrogen Sulfide. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1320.

Goldfrank et. al. Hydrogen Sulfide Poisoning. In: Goldfrank et. al. Goldfrank’s Toxicologic Emergencies. New York, NY: McGraw Hill. 2002. 1504-1507.

Gresham, C. Hydrogen Sulfide Poisoning. Medscape: http://emedicine.medscape.com/article/815139-overview. Updated Jan 27, 2014. Accessed Aug 8, 2014.

==Source==
<references/>

[[Category:Tox]]

Typhoid fever

2014-08-12T14:51:08Z

Cathylewwho:

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==Differential Diagnosis:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment==
*Consultation with Infectious Disease should be considered since there are increasingly multidrug resistant strains of S. Typhi and coinfection with diseases such as [[Malaria]] may complicate treatment. The therapy favors the use of fluorquinolones unless suspected or known resistance.<ref>Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489205/pdf/bmj33300078.pdf PDF]</ref>
===Antibiotics===
'''Oral therapy with Quinolone Susceptibility:'''
*Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days

'''Parenteral Therapy with Quinolone Susceptibility: '''
*Ciprofloxacin 400 mg IV q 12 hrs x 10 days

'''Parenteral Therapy with Quinolone Resistance:'''

''if nalidixic acid resistant, can assume fluoroquinolone resistant''
*Ceftriaxone 2mg IV q 24 hrs x 14 days
::'''OR'''
*Cefixime 10-15 mg/kg IV q 12 hrs x 8 days
'''Oral Therapy with Quinolone Resistance:'''
*Azithromycin 1 g PO daily x 5 days

===Adjunctive Therapy===
If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition==

Admit if any complication

==Sources==

<references/>

Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2011. 1082-1084.

Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Typhoid fever

2014-08-11T20:58:18Z

Cathylewwho:

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==Differential Diagnosis:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment==
*Consultation with Infectious Disease should be considered since there are increasingly multidrug resistant strains of S. Typhi and coinfection with diseases such as [[Malaria]] may complicate treatment. The therapy favors the use of fluorquinolones unless suspected or known resistance.<ref>Bhutta ZA. et al. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8;333(7558):78-82. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489205/pdf/bmj33300078.pdf PDF]</ref>
===Antibiotics===
'''Oral therapy with Quinolone Susceptibility:'''
*Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days

'''Parenteral Therapy with Quinolone Susceptibility: '''
*Ciprofloxacin 400 mg IV q 12 hrs x 10 days

'''Parenteral Therapy with Quinolone Resistance:'''

''if nalidixic acid resistant, can assume fluoroquinolone resistant''
*Ceftriaxone 2mg IV q 24 hrs x 14 days
::'''OR'''
*Cefixime 10-15 mg/kg IV q 12 hrs x 8 days
'''Oral Therapy with Quinolone Resistance:'''
*Azithromycin 1 g PO daily x 5 days

===Adjunctive Therapy===
If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition==

Admit if any complication

==Sources==

<references/>

Tintinalli et. al. Typhoid Fever. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2010.

Hohmann, E. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever . In: UpToDate. Last updated: July 2013. Accessed July 30, 2014.

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Hydrogen sulfide toxicity

2014-08-11T20:52:40Z

Cathylewwho:

Hydrogen Sulfide Poisoning. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==General Information:==

Colorless, flammable gas

Encountered in following industries: oil, gas, organic decomposition (sewer and manure), roofing asphalt tanks

Most common fatal gas exposure

“Rotten egg” smell which diminishes with high concentrations or prolonged low concentration exposure

Often used in suicide attempts: acidic detergent (toilet bowl cleaner) is mixed with bath salts or pesticides

==Mechanisms of toxicity:==

*Highly lipid soluble

*Disrupts oxidative phosphorylation by inhibiting cytochrome oxidase aa3 (toxicity through cellular asphyxia and impairs ATP production) => lactate accumulation and metabolic acidosis

*Causes hyperpolarization of potassium-mediated channels in neurons

*Potentiates neuronal inhibitory mechanisms

*Alters brain neurotransmitter content and release

==Symptoms:==

*Respiratory: dyspnea, cyanosis, hemoptysis, rales, delayed pulmonary edema

*Ophthalmic: conjunctivitis, corneal ulceration, corneal scarring

*Central nervous system: headache, weakness, disequilibrium, intention tremor, muscle rigidity, loss of consciousness, seizures, coma

*Gastrointestinal: green-gray line on gingiva, nausea, vomiting

*Cardiovascular: chest pain, bradycardia

*Neuropsychiatric: amnesia, lack of insight, disorientation, delirium, dementia
*Death

==Differential Diagnosis:==

Carbon Monoxide Toxicity

Cyanide Toxicity

Hydrocarbon Toxicity

Smoke Inhalation Injury

==Diagnosis:==

*No single test to verify exposure or levels

*ABG: metabolic acidosis and normal oxygen saturation (unless pulmonary edema present)

*Elevated lactate

*Discolored copper coins found on patient may be helpful in diagnosis

==Treatment:==

*Removal from source

*100% oxygen

*Can give nitrite component of cyanide antidote kit (do NOT give the thiosulfate portion):
**Theoretically increasing methemoglobin formation in blood will cause conversion of sulfide to sulfmethemoglonin (less toxic)
**Sodium nitrite (3% NaNO2) IV over 2-4 minutes
**Adult dose: 10 mL
**Obtain methemoglobin level 30 minutes after dose (desired level < 30%)

*Hyperbaric oxygen therapy (though not proven to have any benefit)

==Disposition:==

*Admission, likely to MICU

*Toxicology consult

==Sources:==

Tintinalli et. al. Hydrogen Sulfide. In: Tintinalli et. al. Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill. 2010.

Goldfrank et. al. Hydrogen Sulfide Poisoning. In: Goldfrank et. al. Goldfrank’s Toxicologic Emergencies. New York, NY: McGraw Hill. 2002. 1504-1507.

Gresham, C. Hydrogen Sulfide Poisoning. Medscape: http://emedicine.medscape.com/article/815139-overview. Updated Jan 27, 2014. Accessed Aug 8, 2014.

==Source==
<references/>

[[Category:Tox]]

Hydrogen sulfide toxicity

2014-08-11T13:32:59Z

Cathylewwho:

Hydrogen Sulfide Poisoning. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==General Information:==

Colorless, flammable gas

Encountered in following industries: oil, gas, organic decomposition (sewer and manure), roofing asphalt tanks

Most common fatal gas exposure

“Rotten egg” smell which diminishes with high concentrations or prolonged low concentration exposure

Often used in suicide attempts: acidic detergent (toilet bowl cleaner) is mixed with bath salts or pesticides

==Mechanisms of toxicity:==

*Highly lipid soluble

*Disrupts oxidative phosphorylation by inhibiting cytochrome oxidase aa3 (toxicity through cellular asphyxia and impairs ATP production) => lactate accumulation and metabolic acidosis

*Causes hyperpolarization of potassium-mediated channels in neurons

*Potentiates neuronal inhibitory mechanisms

*Alters brain neurotransmitter content and release

==Symptoms:==

*Respiratory: dyspnea, cyanosis, hemoptysis, rales, delayed pulmonary edema

*Ophthalmic: conjunctivitis, corneal ulceration, corneal scarring

*Central nervous system: headache, weakness, disequilibrium, intention tremor, muscle rigidity, loss of consciousness, seizures, coma

*Gastrointestinal: green-gray line on gingiva, nausea, vomiting

*Cardiovascular: chest pain, bradycardia

*Neuropsychiatric: amnesia, lack of insight, disorientation, delirium, dementia
*Death

==Differential Diagnosis:==

Carbon Monoxide Toxicity

Cyanide Toxicity

Hydrocarbon Toxicity

Smoke Inhalation Injury

==Diagnosis:==

*No single test to verify exposure or levels

*ABG: metabolic acidosis and normal oxygen saturation (unless pulmonary edema present)

*Elevated lactate

*Discolored copper coins found on patient may be helpful in diagnosis

==Treatment:==

*Removal from source

*100% oxygen

*Can give nitrite component of cyanide antidote kit (do NOT give the thiosulfate portion):
**Theoretically increasing methemoglobin formation in blood will cause conversion of sulfide to sulfmethemoglonin (less toxic)
**Sodium nitrite (3% NaNO2) IV over 2-4 minutes
**Adult dose: 10 mL
**Obtain methemoglobin level 30 minutes after dose (desired level < 30%)

*Hyperbaric oxygen therapy (though not proven to have any benefit)

==Disposition:==

*Admission, likely to MICU

*Toxicology consult

==Sources:==

Tintinalli’s Emergency Medicine

Goldfrank’s Toxicologic Emergencies

Medscape

==Source==
<references/>

[[Category:Tox]]

Hydrogen sulfide toxicity

2014-08-11T13:32:40Z

Cathylewwho:

Hydrogen Sulfide Poisoning. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==General Information:==

Colorless, flammable gas

Encountered in following industries: oil, gas, organic decomposition (sewer and manure), roofing asphalt tanks

Most common fatal gas exposure

“Rotten egg” smell which diminishes with high concentrations or prolonged low concentration exposure

Often used in suicide attempts: acidic detergent (toilet bowl cleaner) is mixed with bath salts or pesticides

==Mechanisms of toxicity:==

*Highly lipid soluble

*Disrupts oxidative phosphorylation by inhibiting cytochrome oxidase aa3 (toxicity through cellular asphyxia and impairs ATP production) => lactate accumulation and metabolic acidosis

*Causes hyperpolarization of potassium-mediated channels in neurons

*Potentiates neuronal inhibitory mechanisms

*Alters brain neurotransmitter content and release

==Symptoms:==

*Respiratory: dyspnea, cyanosis, hemoptysis, rales, delayed pulmonary edema

*Ophthalmic: conjunctivitis, corneal ulceration, corneal scarring

*Central nervous system: headache, weakness, disequilibrium, intention tremor, muscle rigidity, loss of consciousness, seizures, coma

*Gastrointestinal: green-gray line on gingiva, nausea, vomiting

*Cardiovascular: chest pain, bradycardia

*Neuropsychiatric: amnesia, lack of insight, disorientation, delirium, dementia
*Death

==Differential Diagnosis:==

Carbon Monoxide Toxicity

Cyanide Toxicity

Hydrocarbon Toxicity

Smoke Inhalation Injury

==Diagnosis:==

*No single test to verify exposure or levels

*ABG: metabolic acidosis and normal oxygen saturation (unless pulmonary edema present)

*Elevated lactate

*Discolored copper coins found on patient may be helpful in diagnosis

==Treatment:==

*Removal from source

*100% oxygen

*Can give nitrite component of cyanide antidote kit (do NOT give the thiosulfate portion):
**Theoretically increasing methemoglobin formation in blood will cause conversion of sulfide to sulfmethemoglonin (less toxic)
**Sodium nitrite (3% NaNO2) IV over 2-4 minutes
**Adult dose: 10 mL
**Obtain methemoglobin level 30 minutes after dose (desired level < 30%)

*Hyperbaric oxygen therapy (though not proven to have any benefit)

==Disposition:==

*Admission, likely to MICU

*Toxicology consult

==Sources:==

Tintinalli’s Emergency Medicine

Goldfrank’s Toxicologic Emergencies

Medscape

==Treatment==
#Decontamination of skin/eyes
#O2 100% NRB
#Consider giving nitrite component of CN kit (do not give thiosulfate portion)
##Low level MetHb may enhance conversion of sulfide to less toxic sulfmethemoglobin

==Source==
<references/>

[[Category:Tox]]

Hydrogen sulfide toxicity

2014-08-11T13:32:19Z

Cathylewwho: /* Background */

Hydrogen Sulfide Poisoning. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==General Information:==

Colorless, flammable gas

Encountered in following industries: oil, gas, organic decomposition (sewer and manure), roofing asphalt tanks

Most common fatal gas exposure

“Rotten egg” smell which diminishes with high concentrations or prolonged low concentration exposure

Often used in suicide attempts: acidic detergent (toilet bowl cleaner) is mixed with bath salts or pesticides

==Mechanisms of toxicity:==

*Highly lipid soluble

*Disrupts oxidative phosphorylation by inhibiting cytochrome oxidase aa3 (toxicity through cellular asphyxia and impairs ATP production) => lactate accumulation and metabolic acidosis

*Causes hyperpolarization of potassium-mediated channels in neurons

*Potentiates neuronal inhibitory mechanisms

*Alters brain neurotransmitter content and release

==Symptoms:==

*Respiratory: dyspnea, cyanosis, hemoptysis, rales, delayed pulmonary edema

*Ophthalmic: conjunctivitis, corneal ulceration, corneal scarring

*Central nervous system: headache, weakness, disequilibrium, intention tremor, muscle rigidity, loss of consciousness, seizures, coma

*Gastrointestinal: green-gray line on gingiva, nausea, vomiting

*Cardiovascular: chest pain, bradycardia

*Neuropsychiatric: amnesia, lack of insight, disorientation, delirium, dementia
*Death

==Differential Diagnosis:==

Carbon Monoxide Toxicity

Cyanide Toxicity

Hydrocarbon Toxicity

Smoke Inhalation Injury

==Diagnosis:==

*No single test to verify exposure or levels

*ABG: metabolic acidosis and normal oxygen saturation (unless pulmonary edema present)

*Elevated lactate

*Discolored copper coins found on patient may be helpful in diagnosis

==Treatment:==

*Removal from source

*100% oxygen

*Can give nitrite component of cyanide antidote kit (do NOT give the thiosulfate portion):
**Theoretically increasing methemoglobin formation in blood will cause conversion of sulfide to sulfmethemoglonin (less toxic)
**Sodium nitrite (3% NaNO2) IV over 2-4 minutes
**Adult dose: 10 mL
**Obtain methemoglobin level 30 minutes after dose (desired level < 30%)

*Hyperbaric oxygen therapy (though not proven to have any benefit)

==Disposition:==

*Admission, likely to MICU

*Toxicology consult

==Sources:==

Tintinalli’s Emergency Medicine

Goldfrank’s Toxicologic Emergencies

Medscape

==Clinical Features==
#One of the few chemical asphyxiants that also possesses irritative properities
##Respiratory, ocular irritation
#High conc exposure may result in LOC, seizure, and death after only a few breaths
##Delayed pulm edema and corneal destruction should be anticipated w/ massive exposures

==Treatment==
#Decontamination of skin/eyes
#O2 100% NRB
#Consider giving nitrite component of CN kit (do not give thiosulfate portion)
##Low level MetHb may enhance conversion of sulfide to less toxic sulfmethemoglobin

==Source==
<references/>

[[Category:Tox]]

Typhoid fever

2014-08-11T02:51:17Z

Cathylewwho:

Typhoid fever

2014-08-11T02:50:59Z

Cathylewwho:

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==Differential Diagnosis:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment:==

Ceftriaxone 2mg IV q 24 hrs x 14 days

Ciprofloxacin 400 mg IV q 12 hrs x 10 days; Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days; if nalidixic acid resistant, can assume fluoroquinolone resistant

Azithromycin 1 g PO daily x 5 days

Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition:==

Admit if any complication

==Sources:==

Tintinalli

UpToDate

==Treatment==
# tx empirically with flouroquinolone or 3rd gen cephal
# vaccine partially effecive and breakthrough infc possible

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Typhoid fever

2014-08-11T02:50:46Z

Cathylewwho:

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==Differential Diagnosis:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment:==

Ceftriaxone 2mg IV q 24 hrs x 14 days

Ciprofloxacin 400 mg IV q 12 hrs x 10 days; Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days; if nalidixic acid resistant, can assume fluoroquinolone resistant

Azithromycin 1 g PO daily x 5 days

Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition:==

Admit if any complication

==Sources:==

Tintinalli

UpToDate

==Differential Diagnosis==
{{Template:Fever in Traveler DDX}}

==Treatment==
# tx empirically with flouroquinolone or 3rd gen cephal
# vaccine partially effecive and breakthrough infc possible

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Typhoid fever

2014-08-11T02:50:16Z

Cathylewwho:

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==DDX:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment:==

Ceftriaxone 2mg IV q 24 hrs x 14 days

Ciprofloxacin 400 mg IV q 12 hrs x 10 days; Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days; if nalidixic acid resistant, can assume fluoroquinolone resistant

Azithromycin 1 g PO daily x 5 days

Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition:==

Admit if any complication

==Sources:==

Tintinalli

UpToDate

==Differential Diagnosis==
{{Template:Fever in Traveler DDX}}

==Treatment==
# tx empirically with flouroquinolone or 3rd gen cephal
# vaccine partially effecive and breakthrough infc possible

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Typhoid fever

2014-08-11T02:49:58Z

Cathylewwho: typhoid fever update

Typhoid Fever. Catherine Neal, MD and Alex Koyfman, MD. Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Symptoms:==

Classic symptoms:

*Bradycardia relative to fever

Initial symptoms:

*Fever

*Abdominal pain

*Headache

Subsequent symptoms:

*Chills (rarely rigors)

*Cough

*Abdominal distension

*Constipation (more common than diarrhea)

*“Rose spots” – truncal light red macular rash (in the 2nd wk)

*Prostration

*Hepatosplenomegaly

*GI bleeding

*Transaminitis

*Leukopenia with left shift (adults)

*Leukocytosis (children)

==Diagnosis and Work-Up:==

Blood culture

Urine culture

Stool culture

“Rose spot” aspiration

Bone marrow culture (most sensitive)

Sensitivity testing for nalidixic acid

==Complications:==

Small-bowel ulceration

Intestinal perforation

Anemia

DIC

Pneumonia

Meningitis

Myocarditis

Cholecystitis

Renal failure

Chronic carrier state

==DDX:==

Malaria

Typhus

Viral hepatitis

Amebic Liver Abscess

Infectious enteritis

==Treatment:==

Ceftriaxone 2mg IV q 24 hrs x 14 days

Ciprofloxacin 400 mg IV q 12 hrs x 10 days; Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days; if nalidixic acid resistant, can assume fluoroquinolone resistant

Azithromycin 1 g PO daily x 5 days

Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

If associated delirium, coma, shock, and/or DIC: Dexamethasone 3 mg/kg IV load over 30 minutes, then 1 mg/kg IV every 6 hours x 8 doses

==Disposition:==

Admit if any complication

==Sources:==

Tintinalli

UpToDate

==Diagnosis==
# fvr, ha
# abd pain, constipation, -diarrhea rare
# leukopenia, thrombocytopenia, dry cough, LN
# insidious onset unlike dengue or rickettsia
# dx by blood cx for salmonella enterica serotype typhi
# serology unreliable

==Differential Diagnosis==
{{Template:Fever in Traveler DDX}}

==Treatment==
# tx empirically with flouroquinolone or 3rd gen cephal
# vaccine partially effecive and breakthrough infc possible

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]

Typhoid fever

2014-08-11T02:42:21Z

Cathylewwho: background updated

==Background==
Diagnosed in 2% of febrile travelers

Caused by ''Salmonella enterica serotype Typhi'' (formerly ''Salmonella typhi'') ''serotype paratyphi A, B, and C''

Endemic in Mexico, Indonesia, Peru, and the Indian subcontinent

Prior vaccination does not exclude infection

Incubation period 1-3 weeks

Chronic carrier state defined as organism in urine or stool > 12 months

Chronic carrier state risk factors: biliary tract abnormalities

==Diagnosis==
# fvr, ha
# abd pain, constipation, -diarrhea rare
# leukopenia, thrombocytopenia, dry cough, LN
# insidious onset unlike dengue or rickettsia
# dx by blood cx for salmonella enterica serotype typhi
# serology unreliable

==Differential Diagnosis==
{{Template:Fever in Traveler DDX}}

==Treatment==
# tx empirically with flouroquinolone or 3rd gen cephal
# vaccine partially effecive and breakthrough infc possible

==See Also==
[[Travel Medicine]]

[[Category:ID]]
[[Category:TropMed]]