diplococcus. Fever, headache, arthralgias, altered mental status, and abnor-
mal vitals may also be found, along with neck stiffness. There is no indica-
tion of meningeal irritation in this patient. Furthermore, the rash of
meningococcemia is distinctly different from that of TSS, involving
petechial, hemorrhagic vesicles, macules, and papules with surrounding
erythema, especially on the trunk and extremities. The treatment is IV cef-
triaxone.(e)Disseminated gonococcemia, usually seen in young, sexually
active females, is caused by N gonorrhoeae.The rash of gonococcemia is
pustular with an erythematous base, rather than petechial and hemor-
rhagic, as are the lesions of RMSF and meningococcemia. It can also be
associated with fever and arthralgias. The treatment is IV ceftriaxone or oral
ciprofloxacin.
174.The answer is c. (Rosen, pp 1928-1937. Tintinalli, p 326.)
Osteomyelitisis an infection or inflammation of a bone with an incidence
following plantar puncture wounds of 0.1% to 2%. For patients overall,
S aureusis the leading cause of osteomyelitis, followed by Streptococcus
species. Pain, swelling, fever, redness, and drainage may all occur, but pain
is the presenting complaint in most cases. Risk factors include trauma,
surgery, soft tissue infections, and being immunocompromised (eg, HIV,
diabetes, IV drug user, sickle-cell disease, alcoholism). Definitive diagnosis
is made by bone scan which will demonstrate osteomyelitis within 72 hours
of symptom onset. Radiographs may be normal early on, but will demon-
strate periosteal elevation within 10 days. ESR is often elevated, but a nor-
mal or slightly elevated ESR does not rule out the diagnosis. The ESR is
most valuable in following response to treatment, as the ESR should fall as
the infection resolves. Blood cultures, which are positive in 50% of cases,
should be used to guide antibiotic treatment. All patients with puncture
wounds should receive tetanus prophylaxis.
(a)Patients with sickle-cell disease and asplenism are at higher risk for
Salmonellaosteomyelitis, although S aureusremains the most common
cause.(b)Pseudomonascauses bone and joint infections primarily in three
settings. First, patients receiving implanted prosthetic devices during
orthopedic surgery are at higher risk for osteomyelitis from Pseudomonas.
Puncture wounds to the foot also increase the risk of osteomyelitis from
Pseudomonas. Pseudomonasdoes not appear to grow on puncture objects,
but rather appears to grow on the footwear and may be inoculated into the
wound. Thirdly, IV drug users may develop hematogenous osteomyelitis,
often in the spine, from Pseudomonasbacteria.(d)For patients overall,
196 Emergency Medicine