Rosen & Barkin's 5-Minute Emergency Medicine Consult (305 page)

• Gonococcal ophthalmia neonatorum:
  
  • Mother with genital tract infection
    
  • Bilateral conjunctivitis 2–5 days postpartum:
    
    • If untreated, leads to globe perforation
      

• Gonorrhea: Ceftriaxone/spectinomycin
  
• Chlamydia: Erythromycin
  

FOLLOW-UP

PID—CDC recommendations

• Severely ill (e.g., nausea, vomiting, and high fever)
  
• Pregnant
  
• Does not respond to or cannot take oral medication
  
• Tubo-ovarian abscess
  
• Other emergency surgical condition possible (e.g., appendicitis).
  

Uncomplicated genital, pharyngeal, or conjunctival infection

• Infertility
  
• Recurrent infection despite multiple therapy
  

• Epididymitis—rule out torsion
  
• DGI—strongly consider in young sexually active patient with acute nontraumatic oligoarthritis or tenosynovitis
  

• American Academy of Pediatrics. Gonococcal infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds.
  Red Book: 2012 Report of the Committee on Infectious Diseases
  . Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  
• Centers for Disease Control and Prevention (CDC). Update to CDC’s Sexually transmitted diseases treatment guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections.
  MMWR Morb Mortal Wkly Rep
  . 2012;61(31):590–594.
  http://www.cdc.gov/mmwr/pdf/wk/mm6131.pdf
  .
  
• Gonorrhea – CDC Fact Sheet: CS115145, Content updated June 2012. Centers for Disease Control and Prevention. U.S., Department of Health and Human Services, Atlanta.
  http://www.cdc.gov/std/gonorrhea/gon-fact-sheet-june-2012.pdf
  .
  
• Marrazzo JM, Handsfield HH, Sparling PF. Niesseria gonorrhoeae. Chapter 212. In:
  Mandell: Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases
  . 7th ed. (c)2009.
  
• Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010.
  MMWR Recomm Rep
  . 2010;59:1–110.
  http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
  .
  

See Also (Topic, Algorithm, Electronic Media Element)

• Chlamydia
  
• Urethritis
  

CODES

• 098.0 Gonococcal infection (acute) of lower genitourinary tract
  
• 098.7 Gonococcal infection of anus and rectum
  
• 098.15 Gonococcal cervicitis (acute)
  

BASICS

• Uric acid deposition into tissues, affecting mainly middle-aged men and postmenopausal women:
  
  • Most common crystalline diseases
    
  • 4 phases:
    
    • Asymptomatic hyperuricemia (serum urate >7 mg/dL)
      
    • Acute gout
      
    • Intercritical gout: Quiet intervening periods
      
    • Tophaceous gout (up to 45% of cases)
      
  • Risk factors:
    
    • Age >40
      
    • Male/female ratio 2:1–6:1 <65 yr old; 1:1 ≥65 yr old
      
    • Hypertension
      
    • Use of loop or thiazide diuretics
      
    • High intake of alcohol, meat, seafood, and fructose-sweetened beverages
      
    • Obesity
      
  • Urologic deposition of uric acid calculi may cause renal dysfunction.
    
  • Associated with avascular necrosis and deforming arthritis
    
  • Most frequent in previously damaged joints, tissues:
    
    • Synovium
      
    • Subchondral bone
      
    • Bursae (olecranon, infrapatellar, prepatellar)
      
    • Achilles tendon
      
    • Extensor surface of the forearms, toes, fingers, ear
      
    • Rarely CNS or cardiac (valves)
      
• Pseudogout: A disorder caused by calcium pyrophosphate crystal deposition:
  
  • Most common cause of acute monoarthritis >60 yr of age
    
  • Risk factors:
    
    • Hypercalcemia (e.g., hyperparathyroidism, familial)
      
    • Hemochromatosis; hemosiderosis
      
    • Hypothyroidism and hyperthyroidism
      
    • Hypophosphatemia, hypomagnesemia
      
    • Amyloidosis
      
    • Gout
      

• Deposition of monosodium urate crystals in tissues from supersaturated extracellular fluid owing to:
  
  • Underexcretion (most commonly) or excessive production of uric acid
    
  • Any rapid change in uric acid levels
    
    • Initiation or cessation of diuretics
      
    • Alcohol, salicylates, niacin
      
    • Cyclosporine
      
    • Lead acetate poisoning
      
    • Uricosurics or allopurinol
      
• Pseudogout occurs secondary to excess synovial accumulation of calcium pyrophosphate crystals
  
• Precipitants for both gout and pseudogout include minor trauma and acute illnesses:
  
  • Surgery, ischemic heart disease
    

DIAGNOSIS

• Gout and pseudogout both present as acute monoarticular or polyarticular arthritis:
  
  • Increased warmth, erythema, and joint swelling are present.
    
  • Early attacks subside spontaneously within 3–21 days, even without treatment.
    
  • Later attacks may last longer, cluster, be more severe, and be polyarticular.
    
• Gout:
  
  • Symptoms present maximally within 12–24 hr.
    
  • Tophi and joint desquamation may be present.
    
  • Women predominantly present after menopause and have polyarticular predominance (up to 70%).
    
  • Less dramatic presentations in immunosuppressed and elderly
    
  • Most common: 1st metatarsophalangeal joint (75%) > ankle; tarsal area; knee > hand; wrist
    
• Pseudogout:
  
  • Typically involves larger joints than with gout
    
  • Most common: Knee > wrist > metacarpals; shoulder; elbow; ankle > hip; tarsal joints
    
  • Monoarticular (25%)
    
  • Asymptomatic (25%)
    
  • Pseudo-osteoarthritis (45%): Progressive degeneration, often symmetric
    
  • Pseudorheumatoid arthritis (in elderly)
    
• Polyarticular variant with fever and confusion
  

• Arthrocentesis and aspiration of tophi:
  
  • Examine aspirant for crystals, Gram stain, cultures, leukocyte count, and differential
    
  • Fluid is typically thick pasty white:
    
    • Gout: 20,000–100,000 WBC/mm
      ³
      ; poor string and mucin clot; no bacteria
      
    • Pseudogout: Up to 50,000 WBC/mm
      ³
      ; no bacteria
      
• Microscopic exam of crystals under polarized light:
  
  • Gout:
    
    • Needle shaped
      
    • Strong birefringence
      
    • Negative elongation
      
  • Pseudogout:
    
    • Rhomboid
      
    • Weak birefringence
      
    • Positive elongation
      

• CBC often shows leukocytosis.
  
• Chemistry panel to assess for renal impairment
  
• Magnesium and calcium, thyroid-stimulating hormone (TSH), and serum iron
  
• Uric acid level has limited value.
  
• If infectious arthritis is suspected:
  
  • Blood and urine cultures
    
  • Urethral, cervical, rectal, or pharyngeal gonococcal cultures
    

• Plain radiographs to assess the presence of:
  
  • Effusion
    
  • Joint space narrowing
    
  • Baseline status of joint
    
  • Contiguous osteomyelitis
    
  • Fractures or foreign body
    
• Acute gout: Soft tissue swelling; normal mineralization; joint space preservation
  
• Chronic gout: Calcified tophi; asymmetric bony erosions; overhanging edges; bony shaft tapering
  
• Pseudogout: Chondrocalcinosis; subchondral sclerosis or cysts (wrist); radiopaque calcification of cartilage, tendons, and ligaments; radiopaque osteophytes
  
• Dual energy CT to assess for kidney stones or soft tissue urate crystals