Quiz 37, May 31th 2019

Question 1

Source image: http://www.emdocs.net/

Which of the following diseases is described by: ‘’Suppurative thrombophlebitis of the internal jugular vein and subsequent disseminated infection, often with septic pulmonary emboli. It usually presents as a prolonged pharyngitis in a patient who is febrile.’’?

A: Ludwigs Angina

B: Lemierre’s Syndrome

C: Retropharygeal abcess

The correct answer is B

Clay Smith mentioned this case report in the NEJM this week.

Always keep Lemierre’s Syndrome in your Dx in patients with a sore throat as you cannot miss this one. The causative organism is most commonly Fusobacterium necrophorum.

Question 2

Which of the following characteristics of bruising in children does not immediately raise concern for non-accidental trauma?

A: Bruising in an under 4 month old

B: Bruising to the frenulum, auricular area, cheek, eyes and sclera

C: Bruises with Patterns: Linear or appearance similar to a known object

D: Bruises to upper arms and upper legs

The correct answer is D

Pediatric EM morsels covered bruises in abuse this week.

Of course, always stay vigilant for non-accidental trauma when a child comes in after trauma.

Remember TEN 4 FACES P:
– TEN (Trunk, Ears, Neck)
– 4 (under 4 months)
– FACES (Frenulum, Auricular area, Cheek, Eyes, Sclera
– P Patterned bruising

Sentinel Bruising & Abusive Injury

Question 3

Source image: https://litfl.com

The past years the Neutrofil / Leucocyte Ratio (NLR) gained a lot of attention. Which of the following statements is true about the NLR?

A: A raised NLR is always caused by en inflammatory process

B: Exogenous steroids do not increase the NLR

C: When a cutoff of 10 is used, the NLR has really good diagnostic performance to detect bacteriemia

D: In every study directly comparing NLR with white blood cell count, the NLR has proven to be far more accurate

The correct answer is D

Josh Farkas covered the NLR in a pretty extensive post this week.

It seems the NLR is far from perfect, but it is cheap, fast and a decent sign of overall badness. It outperforms white blood cell count in diagnosis, prognosis and trajectory. The NLR is raised as a cause of physiologic stress, which can be caused by numerous disease entities (not only inflammatory). Exogenous steroid do increase the NLR. The NLR has pretty poor diagnostic performance for bacteremia (but better than white blood cell count).

PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC

Question 4

Source image: https://litfl.com

Which of the following statements is true about Left Ventricular Assist Devices (LVADs)?

A: Patients with LVADs are preload dependent

B: In case the pump stops, you have to change both batteries simultaneously

C: Most LVADs produce a pulsatile flow

D: The most common complication of an LVAD is hemolysis

The correct answer is A

Adam Gottula covered the LVAD in the latest post on Taming the SRU

Patients with LVADs are very preload dependent. If there is no inflow, the pump will stop working. This is also true in the case of a suction event (in which the septum can collapse which results in flow obstruction). Never change both batteries simultaneously, plug in the LVAD power to wall power. Modern LVADs produce a continuous flow (in contrast to early LVADs, which produced a pulsatile flow). The most common complication is GI bleeding.

Question 5

Source image: https://www.aliem.com

The false morel mushroom is considered a delicatesse in some countries and sometimes eaten by mistake in others. Unfortunately, the mushroom contains the toxic gyromitrin, which can cause seizures, nausea and vomiting, abdominal pain, myalgias and rhabdomyolysis.

What agent should be used to treat seizures due to gyromitrin toxicity?

A: Pyridoxine (vitamin B6)

B: Midazolam or any other benzodiazepine

C: Glucose 50%

D: Thiamine (vitamin B1)

The correct answer is A

ALIEM covered gyromitrin poisoning this week.

The false morel mushroom contains the toxic gyromitrin, which can cause gastro-intestinal symptoms, hepatic failure, seizures, rhabdomyolysis, methemoglobinemia and hemolysis.

Gyromitrin’s metabolite (a hydrazine) prevents the formation of the active form of vitamin B6, which leads to GABA depletion. Seizures due to GABA depletion can be refractory to benzodiazepine therapy. Therefore, pyridoxine in a dose of 50-70mg/kg i.v. should be given in addition to phenobarbital. Further treatment is mainly supportive.

Although the fungus is widely recognized as potentially deadly and prohibited in many countries, it is still highly regarded and consumed in some countries including Finland and Bulgaria. Drying them for ten days and parboiling for at least 2 times can decrease the toxicity of the mushroom.

ACMT Toxicology Visual Pearls: Eating Foraged Wild Mushrooms

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen