CLINICAL CASE VIGNETTE American College of Physicians Residents’ Meeting May 17th, 2016

Timothy Tidwell, M.D., ACP Resident Member Internal Medicine Residency Program National Jewish Health | Saint Joseph Hospital, Denver, CO

CASE PRESENTATION • 26 year old gentleman • Chief Complaint: – Fever – Purulent Penile and Rectal Discharge – Painful Mouth Sores – Bilateral Conjunctivitis

• Symptoms began 4 days prior to arrival

CASE PRESENTATION • Previously healthy • Visited urgent care multiple times in past 2 weeks – Initial visit: URI symptoms treated with Penicillin – Subsequent visit: fevers, penile/rectal discharge, conjunctivitis, mouth lesions treated with Acyclovir

CASE PRESENTATION • Worsened – Increased pain – Difficulty with po intake – Continued fevers

• 2 prior episodes mouth sores past 8 years – Similar symptoms – Less severe

CASE PRESENTATION • PMH: Nodular Cystic Acne • SH: – Heterosexual encounter past 2 weeks, new partner • Inconsistent condom use

– Denied other high risk sexual behavior including: • • • •

History of STI Engaging in sex with men Receiving money in exchange for sex Engaging in oral or anal sex

CASE PRESENTATION • SH (cont.): – Former Smoker – Current Alcohol Use • 7-10 drinks 2x per week

– Denies IVDA – Endorses cocaine and LSD use

PHYSICAL EXAMINATION • VS – tachycardic HR 100, Febrile 100.9F • Neck – no lymphadenopathy • GU – purulent urethral discharge, no groin lymphadenopathy • Rectal – pain with DRE, purulent discharge

DATA • CBC, BMP, and LFTs unremarkable • Urinalysis unremarkable • Chest X-ray unremarkable

DIFFERENTIAL DIAGNOSIS ???

DIFFERENTIAL DIAGNOSIS 1. 2. 3. 4. 5.

Disseminated Gonorrhea Viral Infection – e.g. Coxsackie Virus Secondary Syphilis Chlamydia Acute HIV Infection a) Opportunistic infection – e.g. candidiasis

6. Reactive Arthritis (previously Reiter’s Syndrome) 7. Herpes Simplex Virus

DATA – ALL NEGATIVE! HIV rapid and RNA quantitative RPR GC/Chlamydia Cultures of Blood, Ocular Discharge, and Urethral Discharge • Nasopharyngeal Viral Panel by PCR • HSV PCR • + IgM for Mycoplasma pneumoniae • • • •

CASE CONCLUSION • Dx: Erythema Multiforme Major – Secondary to Mycoplasma Infection

• Rx: – Doxycycline and Prednisone taper x 2 weeks – Prednisolone drops for conjunctivitis – Viscous Lidocaine for painful oral lesions

ERYTHEMA MULTIFORME MAJOR • Uncommon (< 1% of the population) • Immune mediated disorder • Presents with cutaneous &/or mucosal lesions – Target Lesions (MINOR): asymptomatic – Mucosal Lesions (MAJOR): painful

• Etiology: – Most commonly HSV – Mycoplasma pneumoniae well documented

ERYTHEMA MULTIFORME MAJOR • Mild-Moderate cases – Supportive treatment

• Severe cases – Pain control • Topical agents • Oral opioids

– Oral corticosteroids

RECURRENT ERYTHEMA MULTIFORME • Uncommon • Definition: – 6+ episodes annually – Severe recurrent episodes

• HSV: continuous systemic antivirals • If failure with antivirals, or unknown etiology: – Azathioprine, Mycophenolate mofetil, or Dapsone

DIAGNOSTIC ERROR • Reduce Medical Errors • Anchoring Heuristic • Premature closure error – Continually expand your differential diagnoses

REFERENCES 1. 2.

3. 4. 5. 6.

7. 8.

http://www.medicinenet.com/imagecollection/erythema_multiforme_1_picture/picture.htm http://www.uptodate.com/contents/pathogenesis-clinical-features-and-diagnosis-oferythemamultiforme?source=search_result&search=erythema+multiforme+adult&selectedTitle =1~150 http://www.uptodate.com/contents/treatment-of-erythemamultiforme?source=machineLearning&search=erythema+multiforme+adult&selectedT itle=2~150§ionRank=3&anchor=H18#H18 http://www.ncbi.nlm.nih.gov/pubmed?term=6345608 http://jama.jamanetwork.com/article.aspx?articleid=386873 http://onlinelibrary.wiley.com/doi/10.1111/j.13652133.1995.tb05024.x/abstract;jsessionid=C8612E1A72F45FEEC4DD020EDAC58148.f 01t01?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+14t h+May+11%3A00-14%3A00+BST+%2F+06%3A00-09%3A00+EDT+%2F+18%3A0021%3A00+SGT+for+essential+maintenance.Apologies+for+the+inconvenience http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0714.1995.tb01122.x/pdf http://www.bmj.com/content/353/bmj.i2139

THANK YOU! QUESTIONS? Timothy Tidwell, M.D. [email protected]