Case Conference - Dr. Kiefer

Case 1: Tattoo Reactions

• Allergic Reactions usually from red dye pigment
  
• Light reactions usually from yellow dye pigment
  
• Can be range of severity from granuloma or erythema to frank ulceration to anaphylaxis
  
• Treatment: Attempt topical steroids.  Usually requires removal.  Caution: warn patients they can have anaphylactic reactions during removal as pigment is dispersed, consider EPI Pen!
  

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Case 2: Missed Central Cord Injury in Intoxicated Motor Vehicle Collision

• Sign out of trauma patients must include concerns and expectation of complete tertiary survey
  
• Take “drunk patient, just needs to sober up” out of vocabulary when transferring care
  
• Pre-existing spondylosis is MAJOR risk factor for central cord injury even after mild trauma. I.E. Fall from standing.  Don’t assume neurological complaints are pre-existing.
  
• Treatment: Collar and admission to ensure no worsening of neurologic function.  This is an evolving injury!
  

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Case 3: Secondary Syphilis

• Classic are copper colored macules on palms and soles +/- exfoliation.  Non-painful and non-pruritic.
  
• DDx to consider: Erythema multiforme, RMSF, meningococcemia, Hand-foot-mouth disease
  
• Tx: Penicillin G LA 2.4 million units IM x1 (for primary of secondary)
  
• Note: Jarisch Herxheimer Rx- fever, fatigue, myalgias, headache, tachycardia following administration of treatment and destruction of spirochetes.  Self limited and resolves 24-48 hours but can be severe.  Treat with NSAIDs.
  

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Case 4: Osteomyelitis in Adolescent

• ALWAYS consider osteomyelitis in patient with pain with movement of an extremity, refusal to bear weight or pain to palpation over boney structure (it’s not just rule out septic joint!)
  
• Usually patients will have vague systemic symptoms (ex. Fever, fatigue, headache, etc.) so we must keep a high level of suspicion.
  
• If there is a concern get testing:  CRP >10 is ~90% sensitive a few days into illness, however, standard of care is MRI (Xrays are frequently completely normal)
  
• It is always reasonable to have a patient return to ED in 24 hours for re-evaluation
  

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Case 5: Guttate Psoriasis

• Generally rare disease process, but most common in children and young adults <30 years old
  
• >50% associated with recent or active group A streptococcal infection
  
• Heralded by acute eruption of erythematous, patches, +/- some scale.  Often mildly pruritic.  Typically begins over proximal extremities and spreads to trunk.  Guttate means “drop” and rash typically appears as “drops” over the skin surface in appearance.
  
• Treatment: Phototherapy and topical steroids.  For recurrent can consider tonsillectomy if secondary to recurrent GAS infections.