EMU Monthly – November 2015

All the EMU goodness for November 2015
1) I want to say a word about Transexamic Acid for bleeding. If you have been following EMU we have spoken about this often and in this article we see that – in a single trial – this medication significantly reduced postpartum hemorrhage, duration of bleeding and need for transfusion. (BJA 114(4)576) The problem is – like most studies with this drug – is the design was poor. I think – and my experience also seems to point in this direction – that the effects are going to be proven to be mild. The difference with this med is that we have known about it for many years and it has a proven safety record. It is also very cheap and seems not to cause a pro coagulation state- which killed Factor Seven. TBTR: TXA may be helpful in post-partum bleeding.
2) I think we discussed this before. Actually after doing an EMU search I discovered a lost sock and that we discussed this back in July 2014. But it is good to review. Laundry detergent pods cause neuro findings, ocular damage, and now also – respiratory compromise. Take kiddies exposures to this seriously (although regular detergent is usually innocuous) (AJEM33(3)349) TBTR: Detergent capsules are dangerous!
3) This is an opinion piece for the CCM folks. One ought to be careful about submersing patients- giving excess IV fluids- even in septic shock- it increases mortality and possibility of ARDS. Wanna keep a good eye on fluids in the body? Forget the CVP – it is totally unreliable. They push for using echo (or I might add ultrasound of the vena cava) to guide you (ibid 448). I think if you do not have this, most EM folks are still giving plenty of fluids- let’s see what our CCM guys have to say. TBTR: Easy on over use of fluids for shock patients. Time for quotes. I know that wit is not so funny but there is some intelligence to it- let us start with the wit folks for the past- beginning with James Thurber
Well, if I called the wrong number, why did you answer the phone?
Early to rise and early to bed makes a male healthy and wealthy and dead.
4) Just in case one of our EMS readers saw this article (do ambulances have restrooms? If not, when do you guys read EMU?) They retrospectively looked at midazolam and diazepam for seizures in the field. They noted that diazepam IM worked only about 50% of the time – not that good(Prehosp Emerg Care 19(2)218) But looking at the statistics a little better- IV – they were similar in efficacy – expected because valium IM is not very well absorbed. However what really blew my mind here is that both failed about 40% of the time when given IV. Seems odd, especially since the dosages for most ambulance crews were reasonable. TBTR: Seizures in the field. Midazolam is better IM than Valium. They are similar for IV. Don’t get it right, just get it written All men should strive to learn before they die what they are running from, and to, and why
5) Small study and retrospective image001 but it was from my alma mater, so why not? Epidural intraluminal steroid injections resulted in more frequent ED discharge in our favorite patients- back pain. They got fewer narcotics also. (Pain Phys 18(2)E171). Even with the problems I mentioned, there are still the problems of how skilled these investigators were- and can we match their skill set? Furthermore, what about safety outcomes. And how bad were these back painers? We need a better study. TBTR: Steroid injections for back pain may lead to faster ED discharge. Boys are perhaps beyond the range of anybody’s sure understanding, at least when they are between the ages of eighteen months and ninety years
The dog has got more fun out of Man than Man has got out of the dog, for the clearly demonstrable reason that Man is the more laughable of the two animals.
6) Fever, flu symptoms, shaking chills, yada yada yada image002Well, of course the first thing you are going to consider is metal fume fever. Well, maybe not, but in a welder or others working with zinc, chromium, nickel copper or manganese- you should think about it. Now there is something which is similar and indistinguishable from metal fume fever, and that is polymer fume fever which is in workers with Teflon and other polymers- both get better with reduction of exposure.(Clin Tox 53(4)195) TBTR: Metal fume fever- of course, you knew that for the boards- but did you hear about polymer fume fever? I’m 65 and I guess that puts me in with the geriatrics. But if there were fifteen months in every year, I’d only be 48. One (martini) is all right, two is too many, three is not enough
7) We spoke a long time ago about catheters that were impregnated with antibiotics that reduced the number of UTIs. They looked at it here and found silver alloy catheters were much more expensive and didn’t significantly reduce the number of infections. (While silver ones didn’t work, they didn’t study diamond studded ones) Nitrofurazone did reduce the amount of infections but just slightly, and were also more expensive and more uncomfortable as well (J Urol 193(4)1263). They didn’t study my favorite catheter – no catheter which has definitely reduces the amount of infections. TBTR: Impregnated catheters do not reduce infection rates. Plutonium ones probably do image003Now over to Will Rodgers for more wit: You can’t say that civilization don’t advance, however, for in every war they kill you in a new way. This country has come to feel the same when Congress is in session as when the baby gets hold of a hammer
8) Bands and rings image005 You know what I am talking about – bariatric surgery seems to cause an increase in kidneys stones. (Kidney Int 87(4)839) The problem with this study aside from being retrospective is that most of the patients underwent Roux EN Y procedures and as such you can only say that Roux En Y can cause more kidney stones. There were too few banding and sleeve procedures to make any conclusions about the others. My surgeons are not sure but they do think there are more biliary stones after bariatric surgery. TBTR: Stones after bariatric surgery – probably increase incidence after malabsorptive procedures. I doubt if a charging elephant, or a rhino, is as determined, or hard to check, as a socially ambitious mother. An onion can make people cry, but there has never been a vegetable invented to make them laugh
9) I lost track – have I mentioned this before? I think I did. Dexetomidine – and if you don’t have this- then light sedation is the way to go for intubation. Benzos cause more problems with weaning and more ICU days (Crit Care 19:136). If you board ICU patients in the ED- you should think in terms of opiods or light sedation TBTR: Sedation – go with sedation lite image006 for intubated patients .
10) More negativity on shift work. Due to melatonin reduction there is more insulin resistance and as such – fatter people. This of course goes with the increased stress, unhealthy eating, and sedentary lifestyle and voila- you got a diabetic. (Int J Endo 26249 2015) We are here just for a spell and then pass on. So get a few laughs and do the best you can. Live your life so that whenever you lose it, you are ahead What the country needs is dirtier fingernails and cleaner minds
11) Dealing with the trauma from the event. Avoidance of pain. Ultimate independent living. This is what burn patients (although they only studied patients with hand burns) want. Nothing remotely new here but it is about time we published some papers with the patient’s perspective (Disabil Rehab 37(10)892) People often ask me, ‘Will, where do you get your jokes?’ I just tell ’em, ‘Well, I watch the government and report the facts, that is all I do, and I don’t even find it necessary to exaggerate. Never miss a good chance to shut up
12) Wanna know how to anesthesize a finger? Then do a digital nerve block. Don’t know how to do it? Then see this article. But if you read EMU you already know how to do this – at least three ways – but I did find something in this article –after careful searching that I did not know. Ropivicaine is a good anesthetic. It combines the advantages of bupivicaine – longer acting and lidocaine- fast onset. This medication starts to work within seconds and lasts 6-20 hours. Another benefit is that it is not a vasodilator like lidocaine. ( Derm Clin 33(2) 265).I have absolutely no experienced with this and I imagine it may not be so cheap. Readers want to help me out?? No need- I checked it out- it is cheap but curiously- on Medscape they report a T 1/2 of only 6 hours. TBTR: Ropivacaine – no pain, no bleeding, longer lasting. Tastes great. Less filling image007
13) Time for a clinical quiz- has been a while for this one. This is a case of an 11 year old boy complaining of hip pain after kicking a soccer (foot) ball. Here is the x ray: image009 What is it, Einstein? (BMJ 350:H1944) Always drink upstream from the herd There are three kinds of men: The ones that learns by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves
14) If you need a paper on energy drinks this is a review but nothing really that new-these are a problem of young males, who are risk taking and/or substance abusers. The side effects are CV and neuro- basically what you would expect in caffeine overdose. (Postgrad Med 127 (3)308) Now over to Dorothy Parker If I didn’t care for fun and such,
I’d probably amount to much.
But I shall stay the way I am,
Because I do not give a damn.

Razors pain you,
Rivers are damp,
Acids stain you,
And drugs cause cramp.
Guns aren’t lawful,
Nooses give,
Gas smells awful.
You might as well live.

15) Kids suffering – a desperate subject that really needs more study. This is a start. These are perhaps not generalizable. These are Dutch children and this is a PICU, not an ED. And it was a survey. But still we do not see enough of these studies. The survey of parents revealed that they associate children’s suffering with what they see – kids crying, and wincing. Nurses associate pain with the child’s presumed comfort level. Physicians with the intensity of treatment and trauma from the treatments. (Eur Ped 174(5)589) TBTR: Suffering of children – some aspects. By the time you swear you’re his,
Shivering and sighing,
And he vows his passion is
Infinite, undying,
Lady, make a note of this —
One of you is lying

Some men tear your heart in two,
Some men flirt and flatter,
Some men never look at you,
And that clears up the matter

16) Tetracycline – this if used in kids under eight can cause browning of teeth. But you don’t use tetracycline any more and I don’t know anyone who does. But you may use the tetracycline family and do they do the same thing? Well this had to be a cohort study for obvious reasons and on an Indian reservation in Arizona where they have a lot of Rocky Mountain Spotted Fever- they gave kids doxy and followed them and found they had no staining at all. True this was only 58 patients but when there is no choice … (J Peds 165(5)1246) TBTR: Doxy can be used in kids without worrying about their teeth- maybe. They sicken of the calm, who knew the storm. (my note-:doesn’t that describe us EPs) It costs me never a stab nor squirm
To tread by chance upon a worm.
“Aha, my little dear,” I say,
“Your clan will pay me back some day.”
17) The cute little article image010wants to give us eight principles for safe opioid prescribing. I will mention the principles but I must mention that this article really besmirches benzos – especially when used with opioids. I can’t agree more- I rarely use these drugs. These drugs are second to opioids in prescription deaths and in non-medical use (that is: abuse) Well here are the eight principles. Assess for misuse potential. See if you are dealing with a co morbid mental disease and make sure your opioids don’t antagonize the concomitant medical therapy. In patients taking opioids chronically, titrate the dose downward when changing to a different opioid. Two-Careful – many folks take benzos for sleep. Methadone – start low – the analgesic effect last only 4-8 hours but the half-life is anywhere between 8-59 hours and can be up to 130 hours(key point here – methadone is being used a lot by cancer docs and the absorption is really not dependable – be careful with kids that may have gotten into this – a six hour observation period is not enough), careful with patients who may have sleep apnea, asthma, and URI; long acting opioids are not indicated for post op acute pain or any acute pain for that matter. ( Postgrad Med 127(1)27) TBTR: Avoid benzos, and be real careful with Methadone. Brevity is the soul of lingerie. This is not a novel to be tossed aside lightly. It should be thrown with great force
18) Sinusitis – there are new guidelines but not much is new. First and foremost – you have to stop giving everyone antibiotics- there are well defined cases when you should but generally – you don’t need them. They do say x rays are unnecessary – and I agree, but curiously they say you may use topical intranasal steroids and/or nasal saline irrigation. No real evidence here for the steroids but Kudos to the writers that they at least go over the evidence and also write if they disagreed. They do not like antihistamines. (Oto Head Neck Surg 152(4)598) TBTR: Sinusitis guidelines. Take me or leave me; or, as is the usual order of things, both Beauty is only skin deep, but ugly goes clean to the bone
19) If you listen to Risk Management Monthly (Hi Father) you know the answer to this one –these cases are like a rat rising to bite you in the tush will cause you to visit the friendly nearest courtroom. But since EMU is an international journal and many folks may not see this – let us open your mind. image01132 year old man with a week of worsening thoracic back pain. He is an IVDA. Blood tests (yea that is the ticket) and a chest film were normal. He then returns and in more pain – this time they do spine films – normal. 2 days later, he comes with fever, back pain and a wide based gait with spasms of the left leg. (BMJ 2015:h1752). OK, what is this? IN the meantime, or next wit is Mark Twain. Soap and education are not as sudden as a massacre, but they are more deadly in the long run. Reader, suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself
20) I was considering this for the essay but this is one strange article Truth be told it doesn’t add much to what we all knew but I will highlight some stuff. It is a current concepts article on management of animal and human bites. Computer bytes were omitted. Dog bites are more common in kids, but cat bites are more often in older ladies – greater than 75 years old (which makes sense – who else would own a cat?). Snake and scorpion bites – are mentioned but really nothing new there. Human bites- well we all know the clenched fist bite is bad news, but the most common human bites problem are- paronychia of course (biting a piece of skin near the nail) and love nips – we won’t get to graphic on that one. Here comes the weird stuff. They say: Obtain culture in abscesses and severe cellulitis – abscesses are treated with lancing in my opinion and if there is neither cellulitis nor a patient with neither diabetes nor other immune suppression – you don’t need to treat with antibiotics. Cellulitis is hard to culture in any case. I’ll give them points for irrigation and a nice discussion of whether or not you can close bite wounds primarily (most can be). But again they delve into weirdness- they bring some study that found no difference in cosmetic results between primary repair or leaving the wound open. They push for three to five days of prophylactic antibiotics for all cat bites (at least for snake bites they say no antibiotics). Moderate or severe bites (what are those?) and delayed presentation they also recommend antibiotics – no literature brought! They say cat bites should not be treated with Augmentin because of poor staph coverage- I thought it was good staph coverage- am I wrong? Then they confusingly say Diclox is also poor overage – then two lines later say it is excellent coverage(the latter is true). These folks were from Arizona and are supposed to know this stuff-maybe it is just me. Ken is also from Tucson (and can probably tell me why Tucson is pronounced too-son and not tuck-son) and probably even knows the authors – I’ll wait to get corrected by Ken. (J Trauma 78(3)641) TBTR: Bites news. Or News Bites. The reports of my death are greatly exaggerated Get your facts first, and then you can distort them as much as you please.
21) Elbow dislocations – when you have no help they can be tough – but this article uses your elbow to immobilize his elbow so you can relocate it There are great color pictures but I don’t want to get into copyright problems so go see the article yourself. My orthopods tried it twice: it worked once and once nothing worked (Orthopedics 38(1)42) Definition of a classic — something that everybody wants to have read and nobody wants to read Always do right. This will gratify some people, and astonish the rest
22) Letters: We gotta thank John for his concerns. Here is his letter: I hope you are staying safe and things have somewhat stabilized in your neck of the woods. While we in the US seemingly have the exclusive market on mass shooting craziness, it is altogether another thing for you to be walking and working among someone who might suddenly pull out a knife and start stabbing away.

Happy Holiday season and will pray for peace.


PS: Please no more fallen idol pictures from my hormonally charged adolescent past. First Olivia, then what? Farrah? Jaclyn (now 70)? Stop the madness!
I am so sorry, John- as Father has pointed out in the past I am in a time warp. And besides my favorite was always Kate Jackson. Anyone know what we’re talking about? John also mentioned passing on my link to others- this is a critical need for me- if you are reading this – pass it on!! Loren Crowns asks –what does TBTR strand for? Many years ago, a reader pointed out that “Take home Message” was too mundane and suggested we use Too Boring to Read. So I did that. Alt5houhg I think all of it is too boring to read. Idan writes: This site is AWESOME!
Thank you guys! Which guys you talkin bout? I am the only moron writing this this stuff. But Idan, now that you mention it…. Ken cheked I a while ago:
A belated L’shana tova!

Liked the new (August) EMU and very sorry to hear that your site was attacked. Glad it’s back up.

If I haven’t told you, I’ve listed you in the Acknowledgements for the second edition of “Improvised Medicine: Providing Care in Extreme Environments” (McGraw Hill). Among my many sources, I review and then use some of the articles from EMU for my new material. I am just finishing reviewing the proof pages and the book should be out in January 2016.

January is just before I return to Antarctica for about seven months. I’ll be the Lead Physician at McMurdo Station over the Antarctic winter, 2016. No sun—and only a gray haze the first couple of weeks I’m there.
Ken doesn’t let grass grow under his feet- thanks always for the support and keep reading EMU down down under!
23) Number 13 the clinical quiz- that was an apopyseal avulsion fracture – that little piece of bone near the iliac spine. I saw a similar case 25 years ago with a kid swinging a bat that used his Sartorius to rip off an apopyseal center. But even if you missed it most do well. There are some non-unions and bony overgrowth causing pain to the sciatic nerve, but these are rare. Treatment is rest- surgery is uncommon. Number 19 was a spinal epidural abscess. Clothes make the man. Naked people have little or no influence on society. Persons attempting to find a motive in this narrative will be prosecuted; persons attempting to find a moral in it will be banished; persons attempting to find a plot in it will be shot.BY ORDER OF THE AUTHOR
Insanity – I am doing four essays this month! Why? There was just good reviews so here we go. Sources for these articles are BMJ 2015:h1563, ibid h1300,Clinics in Derm 2015 33:347, and BMJ 2015 h1825
1) How do you manage acute testicular pain? Oh I know, you gotta’ rule out torsion. And putting the scrotum in a cup of boiling coffee will not rule this out. Will an ultrasound help? Of course it will. Er- read on. Maybe not.
2) Torsion occurs in 1 out of 4000 males under the age of 25 – so it isn’t that uncommon. It can occur in neonates and even in utero. Curiously – the left side is more likely to be affected. True the horizontal lie sign may help but this may occur later on so absence doesn’t mean much. Neonatal torsion is extravaginal and that means there will not be a bell clapper deformity at all. Age may help – torsion is the most common cause of an acute scrotum in the neonatal and post puberty males. But of course this can occur even in older men. Pain can help – torsion is sudden, and may be remitting if there is intermittent torsion. However, neonatal torsion can be pain free. Physical exam is pretty impressive here – it is very painful, high riding and there is swelling. Cremasteric reflex may help- it should be absent in torsion but it is absent in neurologic disease and in neonates. Ultrasound is often done – naturally specificity is very high, but is can miss up to two thirds in some studies. It is operator dependent and is technically difficult in boys before puberty. Doppler may help but 24% of the time there is normal blood flow. High resolution US is better but DO NOT DELAY EXPLORATION. If there will be a delay let the urologist do a bedside 1 cm exploration.
3) Epididymitis and orchitis are infections, which can be from reflux of urine or STD. Discharges or foul smelling urine helps here. The pain is usually sub-acute. Prehn’s sign – lifting up the testicle relieves the pain- may be present here. Urinalysis can help here but if it is normal it doesn’t exclude epididymitis nor does an abnormal UA rule out torsion
4) Torsion of the testicular appendage. Blue dot signs aren’t always present either. Treatment is conservative.
5) Less common causes – AISE – acute idiopathic scrotal edema Occurs under age ten and is unilateral – everything is normal on ultrasound- could be an allergic reaction, but no one knows for sure.
6) Cancer- not usually a cause of an acute scrotum – pain only in 20% of cases. Hydrocele- not usually painful. But varicocele can be (also occurs more often on the left)
7) Other causes: Testicular trauma and do not forget incarcerated hernias, and appendicitis and renal colic – which typically refers to the scrotum.
8) Treatment – torsion – first they may soak the testis in warm water to see if it is viable (again, do not use boiling coffee for this). True the time to surgery is important, but there is no clear amount of time that it can be said it is too late. Epididymitis is scrotal support, analgesia, and antibiotics unless it is before puberty where the disease is self-limited. Abscesses can occur. Mumps can have superimposed bacterial infection but barring that – it is also treated conservatively.
Four essays can be boring-here is some more wit- Ogden Nash for you: Every New Year is the direct descendant, isn’t it, of a long line of proven criminals?

To keep your marriage brimming,
With love in the loving cup,
Whenever you’re wrong, admit it;
Whenever you’re right, shut up.
Dental Infections
1) Yea these are easy too, Call a dentist. But dental infections can spread –even hematogenously and this can result in badness. And calling the dentist. In the UK they have on for every 100 people, but good luck in the sub Saharan area of Africa- one dentist for every 900000 people.
2) First of all – know the enemy lurking within image012Strep Angionosus, Prevotella and our old pal fusobacterium. PCNS and macrolides work well, and you rarely need flagyl – only if there is a high prevalence of beta lactamase provatella image013in the community but as we will soon see, it is isn’t too common that you will actually need antibiotics.
3) You should be able to make a diagnosis here. Here are your choices. Jaw pain made worse by hot and cold, and in later stages- pain on chewing is pulpitis – or for you simpler folks – toothache. Antibiotics are often given but they are ineffective- this needs surgical treatment. Dull pain may be bite disorders or TMJ syndrome. Sinusitis can give a toothache type pain – but there is usually a blocked nasal passages. Parotitis is another DDX. Sialothiasis can cause pain while salivating – like even thinking about food. Trauma- of course- and rare causes- trigeminal neuralgia – more of an electric pain – and giant cell arteritis.
4) Maxillofacial swelling – this is more dangerous and needs antibiotics and dental treatment fast.
5) Wanna to do a test? Panoramic x rays is great but do not show good resolution of the anterior teeth. Periapical views are better and are not hard to read in my opinion but they are not usually available in the ED.
6) Antibiotics are never a solution without swelling outside of the mouth. They bring many studies confirming this but I must say I am dubious- I think there may be a subset that does respond. And for sure for periodontal disease they work. But they are truly unnecessary for post root canal and post extraction.
7) Two preventive measures that I did not know about –beware of the dry mouth – give folks chewing gum (sugarless of course) because dry mouth can cause dental caries. Also when brushing, don’t wash out your mouth rather spit out the toothpaste and that is it. Nothing like the wonderful Crest taste in your mouth all day.
I think that I shall never see
A billboard lovely as a tree.
Indeed, unless the billboards fall,
I’ll never see a tree at all.

1) I’m not one to bandy anyone’s name in public but this cute little critter is annoying but innocuous image014.What am I speaking about – I am just itching to speak about the an update on lice If you think this is cute you probable will think this is too!image016

2) Lice don’t jump from head to head. Rather, it comes from head to head contact and the sharing of headgear and combs/brushes. As a result – lice will be more common in school age kids and more so in girls. Because of hair differences, lice are less common in people of African extraction. They do suck blood and they need humans to live – without a host they die within 36 hours (warmer climates may allow up to ten days of life). Nits usually are found within 6 mm of the scalp or the nape of the neck in warmer climates. But we do not want to speak a lot about lice –we have come to bury Caesar not to praise him 3) Let’s speak about treatment. Benzyl alcohol – you know – that stuff that is a preservative in certain injectables- comes now in a lotion. This works by opening respiratory spicules in the little critters and allows the oil containing vehicle to asphyxiate them (hooray) This is a pretty cheap treatment, but there are a lot of side effect- neonatal gasping syndrome (not for use under age six months) , irritation, erythema and pruritis. Lindane is an old favorite – it is a neurotoxin, but can cause seizures in little ones and in those with seizure disorders. It is also contraindicated in HIV patients, thin patients and older individuals. There is a high rate of neuro effects including vertigo, tremor and aphasia – so this is a second line medication. In Israel it is academic, since our lice are resistant. It is also the least effective against eggs. 4) Spinosad is an effective lice killer and egg killer. Very few side effects. Cost? 5) Malathion is a weak organophosphate, and I understand that the poison control center of the Lice nation is distributing atropine to all lice to protect them. All seriousness aside, it is in an alcohol base and as such is very flammable. Obviously, if it ignites it will kill all the lice as well. It is ovicidal. But resistance has been reported in Europe and Israel.
6) Ivermectin is a scabiacide and as a lotion is now in use for lice. It can also be given in a single dose pill form and is very effective even against eggs. However, over dosage can be treacherous.
7) TMP SMX kills the enteric bacteria that lice need for digestion but it’s use is off label. It also cures their UTIs.
8) OTC in the USA include permethrin – a neurotoxin that does not kill eggs but there is a lot of resistance- some rates of effectiveness are in the forty percent range. It can cause asthmatic exacerbations
9) Pyrethrin come from chrysanthemums, and is also a neurotoxin. There is some ovicidal activity – but there is also a lot of resistance.
10) Olive oil, melted butter, mayonnaise. These are supposed to asphyxiate them but it takes a long time to do this (at least eight hours) All of these are effective in causing delay in hatching, but only petroleum jelly kills any reasonable amount of them.
11) They do discuss combing, they do not discuss it’s effectiveness nor the newer electric shocking combs.
• Some various wit quotes: Everyone has the right to be stupid, but you are abusing the privilege
• Energizer Bunny arrested — charged with battery…
• Dijon vu — the same mustard as before

1) Well we could only be talking about mono. The classic triad is fever, pharyngitis, cervical lympahadenitis, and lymphocytosis (that’s really a quadriad but that’s too bad).
2) Interesting. EBV doesn’t cause all the cases of mono- CMV, herpes 6, toxo, HIV and adenovirus are also causes. And to make you more nuts- there is an ICD code for Filatov’s disease, Drusenfieber and Pfeiffer’s disease- which are all mono. So is kissing disease.
3) EBV infects 60% of the population and stays with us for our life – it incorporates itself into replicating B cell lymphos. It is then shed via the saliva and that explains why it isn’t a good idea to kiss that cutie with the boyish bobimage017
4) Most symptoms take 2- 4 weeks to go away but the sore throat can persist up to a month. Lymphoma and HIV can reactivate the virus, but a chronic active infection is rare.
5) Diagnosis: lymphadenopathy is more prominent in the anterior and posterior triangles as opposed to bacterial tonsillitis which is the anterior chain. Other signs are petechia on the palate, splenomegaly and hepatomegaly. LFT elevation is seen in most patients. There is a complete whiteout on the tonsils as opposed to the speckled appearance of the exudate in bacterial tonsillitis and erythema of viral tonsillitis. Heterophile tests are very unreliable, but EBV IGM will help clinch the diagnosis.
6) Treatment: What not to do – don’t give Ampicillin (is anyone still using this in the ED?), do not give acyclovir- it will lead to less viral shedding but hasn’t shown to help the clinical picture. Other antivirals- are now being investigated. Flagyl may actually help by suppressing oral flora that contribute to the inflammation. Steroids- have a short lived effect and are recommended only at this point for airway emergencies.
7) Does IM cause chronic fatigue syndrome? Maybe – in 12% of cases but even that isn’t certain. EBV is present in all cases of multiple sclerosis but it is hard to say there is a connection.
8) Cancer? Yes for Burkitt’s, nasopharyngeal cancer and Hodgkins. Others – probably not.
9) Complications of IM include neuro stuff-Guillain Barre, hearing loss. Optic neuritis, encephalitis seizures, facial palsy and Alice in Wonderland syndrome (see last month’s EMU). All this makes sense as this is a herpes virus. Heme problems are more common, and include anemia and thrombocytopenia, but aplastic anema can occur. Other side effects are rarer. Surprisingly they do not speak about splenic rupture.

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