Rosen & Barkin's 5-Minute Emergency Medicine Consult (304 page)

• Nephritic Syndrome
  
• Nephrotic Syndrome
  
• Renal Failure
  

CODES

• 580.0 Acute glomerulonephritis with lesion of proliferative glomerulonephritis
  
• 583.4 Nephritis and nephropathy, not specified as acute or chronic, with lesion of rapidly progressive glomerulonephritis
  
• 583.9 Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney
  

BASICS

• 2nd most frequently reported STD in US:
  
  • Estimated 820,000 new cases per year
    
  • <50% reported
    
  • Highest rates in 15–24-yr-old males and females, African Americans
    
  • Increasing incidence in men who have sex with men (MSM):
    
    • Higher in HIV-positive individuals
      
  • Humans only known host
    
• Concurrent infection with
  Chlamydia trachomatis
  is common
  
• Affects the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctiva
  
• Urethritis most common presentation in men
  
• Often asymptomatic in women
  

Neisseria gonorrhoeae
:

• Gram-negative aerobic diplococci
  

DIAGNOSIS

• Cervicitis:
  
  • Defined as:
    
    • Mucopurulent endocervical discharge; OR
      
    • Easily induced endocervical bleeding
      
  • Most common site of infection
    
  • Up to 80% asymptomatic
    
  • Most symptoms nonspecific:
    
    • Vaginal discharge
      
    • Menorrhagia
      
    • Pelvic pain
      
    • Dyspareunia
      
    • Frequency and dysuria
      
• Pelvic inflammatory disease (PID):
  
  • Up to 20% of untreated cases
    
  • Lower abdominal pain—most common presenting symptom
    
  • Other common signs and symptoms:
    
    • Dyspareunia, abnormal bleeding, abnormal cervical or vaginal discharge
      
  • Symptoms often occur at onset of menses.
    
  • Fever (50%)
    
  • 2/3 have mild, vague symptoms; may go unrecognized
    
  • Fitz-Hugh–Curtis syndrome: (perihepatitis):
    
    • 10% occurrence rate
      
    • Right upper quadrant pain/tenderness
      
• Bartholin abscess
  
• Urethritis:
  
  • Incubation period 2–5 days
    
  • Symptoms:
    
    • Penile discharge
      
    • Dysuria
      
• Prostatitis—can occur in untreated urethritis
  
• Epididymitis:
  
  • Acute, unilateral testicular pain and swelling
    
• Proctitis:
  
  • Often asymptomatic
    
  • Only site of infection in 40% of MSM
    
  • Rectal infection occurs in 35–50% of women with endocervical infection
    
  • 3-fold increase in HIV infection risk
    
  • Symptoms:
    
    • Perianal pruritus, mucopurulent discharge, mild rectal bleeding, severe rectal pain, tenesmus, and constipation
      
• Pharyngitis:
  
  • Sore throat, exudative tonsillitis
    
• Disseminated gonococcal infections (DGI):
  
  • Gonococcal bacteremia
    
  • Arthritis: Dermatitis syndrome:
    
    • 0.5–3% of untreated mucosal infections
      
    • Triad of tenosynovitis, dermatitis, and polyarthralgia
      
    • Fever, chills, malaise
      
  • Dermatitis:
    
    • Tender necrotic pustules on an erythematous base, few lesions, begin distally
      
  • Acute monoarticular or oligoarticular arthritis:
    
    • Knee most common
      
    • Warm, erythematous joint with effusion and pain with range of motion
      
  • Female > male, 3:1:
    
    • Risk factors: Recent menstruation or recent pregnancy
      
  • Rare manifestations:
    
    • Hepatitis
      
    • Myocarditis
      
    • Endocarditis
      
    • Meningitis
      

• Cervicitis:
  
  • Cervical edema, congestion, friability
    
• PID:
  
  • Uterine tenderness, adnexal or cervical motion tenderness
    
• Urethritis:
  
  • Yellow-white thick discharge, urethral meatal erythema
    

• Clinical diagnosis in male gonorrhea:
  
  • Gram stain 95% sensitive
    
• Cervical culture in female gonorrhea
  
• Also test for chlamydia and syphilis
  

• Cultures (gold standard):
  
  • Thayer-Martin medium
    
    • Mainstay for blood and synovial fluid
      
• Gram stain:
  
  • Intracellular gram-negative diplococci:
    
    • Approaches 100% sensitive in symptomatic men
      
• Nucleic acid amplification tests (NAATs):
  
  • DNA or RNA sequences using polymerase chain reaction (PCR)
    
  • Many also test for chlamydia
    
  • Useful in urethral, cervical, and urine specimens
    
• Pharyngeal/rectal cultures for local symptoms in high-risk individuals
  
• DGI:
  
  • Synovial fluid analysis:
    
    • Neutrophilic leukocytosis, >50,000 cells/mm
      ³
      
    • Positive cultures when >80,000 cells/mm
      ³
      
  • 2 or more sets of blood cultures
    
  • Synovial, skin, urethral or cervical, and rectal cultures:
    
    • Thayer-Martin media
      
• PID/lower abdominal pain in female:
  
  • CBC
    
  • Urinalysis
    
  • Pregnancy test
    
  • Consider pelvic ultrasound for tubo-ovarian abscess
    
• Rapid plasma reagin (RPR): For associated syphilis
  

• Urethritis:
  
  • Chlamydia
    
  • Trichomonas
    
  • UTI
    
  • Syphilis
    
• DGI:
  
  • Bacterial arthritis:
    
    • Meningococcus (rash)
      
  • Hepatitis B
    
  • Connective tissue disease:
    
    • Reiter syndrome
      
    • Rheumatoid arthritis
      
    • Psoriatic arthritis
      
  • Acute rheumatic fever:
    
    • Poststreptococcal arthritis
      
  • Infective endocarditis
    
  • Others:
    
    • HIV
      
    • Secondary syphilis
      
    • Viral infection
      
    • Lyme disease (rash)
      
    • Gout (arthritis)
      

TREATMENT

• Hydration (0.9% NS) for nausea/vomiting
  
• Treat sexual partner. For expedited partner therapy jurisdiction –
  www.cdc.gov/std/ept
  
• Patient with gonorrhea should often be presumptively treated for chlamydial infection.
  
• Cervical, urethral, and anorectal infection:
  
  • Ceftriaxone: 250 mg IM once OR
    
  • Also treat for chlamydia:
    
    • Azithromycin: 1 g PO once OR
      
    • Doxycycline: 100 mg PO BID for 7 days
      
• PID:
  
  • Outpatient:
    
    • Ceftriaxone: 250 mg IM once or cefoxitin 2 g IM and probenecid 1 g PO once or another 3rd-generation cephalosporin (ceftizoxime or cefotaxime) + doxycycline 100 mg BID for 14 days with or without metronidazole 500 mg PO BID for 14 days
      
  • Inpatient:
    
    • Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + doxycycline 100 mg PO or IV q12h
      
    • Clindamycin 900 mg IV q8h + gentamicin loading dose (2 mg/kg) followed by (1.5 mg/kg) q8h or 3–5 mg/kg q24h
      
• Pharyngitis:
  
  • Ceftriaxone 250 mg IM single dose + treatment for chlamydia
    
• Epididymitis:
  
  • Ceftriaxone 250 mg IM once + doxycycline 100 mg BID for 10 days
    
• Treat sexual partner
  
• DGI:
  
  • Ceftriaxone: 1 g IV/IM daily (recommended)
    
  • Cefotaxime: 1 g IV q8h OR
    
  • Ceftizoxime: 1 g IV q8h OR
    
  • 24–48 hr after improvement, additional 7 days with:
    
    • Cefixime: 400 mg PO BID OR
      
    • Cefpodoxime: 400 mg PO BID
      
  • Neonates, incl. gonococcal scalp abscess
    
    • Ceftriaxone 25–50 mg/kg/d IV/IM for 7 days OR
      
    • If hyperbilirubinemia-Cefotaxime 25 mg/kg IV/IM q12h for 7 days
      
• Conjunctivitis:
  
  • Adults:
    
    • Ceftriaxone 1 g IM once
      
  • Ophthalmia neonatorum:
    
    • Ceftriaxone 25–50 mg/kg IM/IV once
      
    • Saline irrigation, hospitalize
      
• Meningitis/endocarditis:
  
  • Ceftriaxone 1–2 g IV q12h:
    
    • 10–14 days for meningitis
      
    • At least 4 wk for endocarditis
      
• Severe cephalosporin allergy:
  
  • Consult infectious disease
    
  • Cephalosporin use postdesensitization best alternative
    
  • Azithromycin 2 g PO for uncomplicated gonococcal infection:
    
    • Limit use to prevent resistance