By F. Navaras. Oregon Health Sciences University. 2018.
The majority of recurrent UTIs occur as a result of unsuccessful erad- ication of the primary infection 78 BOARD REVIEW B order zocor 10 mg visa. The use of spermicide is associated with a decreased rate of recurrence C buy zocor 10mg low price. A maternal history of UTI is an independent risk factor for recurrent UTI D purchase 40 mg zocor with mastercard. A history of first UTI occurring before 18 years of age is associated with recurrent UTI Key Concept/Objective: To understand the risk factors and pathogenesis of recurrent UTI Approximately one in three women with UTI will experience recurrence of infection purchase zocor 40 mg with mastercard. These recurrent infections are caused by either incomplete eradication (10%) or rein- fection (90%). Various risk factors have been associated with increased incidence of UTI, including increased frequency of sexual intercourse, use of spermicide, having a new sexual partner, a history of first UTI occurring before 15 years of age, and a maternal history of UTI. A 32-year-old woman presents to her obstetrics/gynecology clinic for routine follow-up. She states that she was experiencing nausea and vomiting until the 14th week, but since then she has had no complaints. The results of laboratory studies are normal except for uri- nalysis, which shows 3+ bacteria. Which of the following statements is true regarding asymptomatic bacteriuria in pregnant women? Pregnant women with asymptomatic bacteriuria are not at increased risk for perinatal mortality or morbidity B. If not treated, 25% of pregnant women with asymptomatic bacteri- uria will develop pyelonephritis later in pregnancy C. Pregnant women with asymptomatic bacteriuria have the same risk of UTI on long-term follow-up as women without bacteriuria D. Asymptomatic bacteriuria should be monitored closely but treated only after symptoms develop Key Concept/Objective: To understand the evaluation and treatment of pregnant women with asymptomatic bacteriuria The approach to asymptomatic bacteriuria in pregnant women is significantly differ- ent from that in nonpregnant women. Because of the increased incidence of maternal mortality and premature births, asymptomatic bacteriuria in pregnant women is actively sought and is as aggressively treated and followed as symptomatic infection. Pregnant women with untreated bacteriuria are at increased risk for pyelonephritis later in the pregnancy, and there is an increased risk of recurrent UTI on long-term fol- low-up. Treatment of pregnant women with asymptomatic bacteriuria is also more aggressive (in nonpregnant women, bacteriuria is not treated unless symptoms devel- op). In addition, the duration of therapy is longer in pregnant women than in non- pregnant women. She denies having fever, chills, nausea, or vomiting. Previously, she had a UTI, and she wonders whether she can use some antibiotics left over from her previous regimen. Which of the following antibiotics is NOT recommended for treatment of UTI during pregnancy? Ceftriaxone Key Concept/Objective: To know which antibiotics are safe to use in pregnancy For the pregnant patient with UTI, the antibiotic options are significantly decreased because of various fetal toxicities associated with some medications. Nitrofurantoin, ampicillin, ceftriaxone, and other cephalosporins have been considered safe for use in pregnancy. Fluoroquinolones are avoided because of fetal cartilage injury, and trimethoprim-sulfamethoxazole is avoided because of various other toxicities. Aminoglycosides are considered relatively safe and may be used in pregnant patients with pyelonephritis who require I. A 27-year-old woman with diabetes mellitus presents with fever, dysuria, nausea, vomiting, and flank tenderness. Physical examination reveals a young woman in moderate distress. The chest is clear on examination, and the cardiac examination is normal except for tachycardia. The abdomen is benign except for marked costovertebral tenderness on the right. Laboratory results are as follows: WBC, 18,000 with a left shift; BUN and creatinine levels are within normal limits; urinalysis is positive for leukocyte esterase, with 30 to 40 WBC/high-power field; bacteria are too numerous to count. The patient is admitted to the hospital and is treated with I.
A Infiltration of a perineurial vessel wall by mul- tiple inflammatory cells includ- ing lymphocytes and macroph- ages (black arrows) order 20 mg zocor fast delivery. There is also evidence of pink fibrin de- posits consistent with the pres- ence of fibrinoid necrosis generic 20mg zocor with mastercard. B Teased fiber preparations show- ing multiple axon balls (white arrows) and evidence of empty strands consistent with axonal degeneration Fig discount zocor 10 mg online. Dorsal root ganglion bi- opsy from a patient with severe sensory ataxia due to dorsal root ganglionitis generic zocor 20 mg on line. There are clusters of inflammatory cells (white ar- rows) surrounding the dorsal root ganglion neurons (black ar- rows). Many of the neurons show evidence of degeneration 263 Fig. Atrophy of the small hand muscles and vasculitic changes at the nailbed Fig. Vasculitic neur- opathy was heralded by vascu- litic skin changes B Nerve and muscle pathology relates to destruction of blood vessels. Anatomy/distribution Proximal and distal weakness, pain, and sensory loss occur in a multifocal Symptoms distribution. May affect isolated nerves (45% of cases), overlapping nerves (40%), or cause Clinical syndrome/ symmetric neuropathy (15%). Patients typically present with a mixture of motor signs and sensory signs. Associated signs of systemic vasculitic disease include: fever, weight loss, anorexia, rash, arthralgia, GI, lung, or renal disease. Usually the 264 neuropathy presents in patients that have already been diagnosed with a specific vasculitic disease (Fig. Pathogenesis Several immune-mediated mechanisms have been identified that lead to destruction of vessel walls. The various mechanisms result in ischemic necrosis of axons (see Figs. Systemic disease that can involve vasculitic neuropathy can be divided into the following categories: Immune/Inflammatory mediated: Wegener’s granulomatosis (Fig. EMG and NCV are abnormal, and are important for identifying which nerves are involved. SNAPs and CMAPs are reduced reflecting axonal damage. Muscle and nerve biopsies should be taken, and show T-cell and macrophage invasion, with necrosis of blood vessels. Differential diagnosis Diabetic neuropathy, HNPP, CIDP, multifocal neuropathy with conduction block, plexopathies, porphyria, multiple entrapment neuropathies, Lyme dis- ease, sarcoidosis. Therapy The systemic disease should be treated as aggressively as possible. Prednisolo- ne and cyclophosphamide are frequently used in the treatment of systemic vasculitic diseases. Aggressive pain management should be a special concern of the neurologist. Prognosis Therapy leads to improvement in most cases, but residual impairments and relapses are possible. Pain symptoms often respond quickly, but this should not be taken as an indication that the vasculitis is under control. Baillieres Clin Neurol 1: 193–210 Griffin JW (2001) Vasculitic neuropathies. Rheum Dis Clin North Am 4: 751–760 Olney RK (1998) Neuropathies associated with connective tissue disease. Semin Neurol 18: 63–72 Rosenbaum R (2001) Neuromuscular complications of connective tissue diseases. Muscle Nerve 2: 154–169 Said G (1999) Vasculitic neuropathy. Curr Opin Neurol 5: 627–629 265 Vasculitic neuropathy, non-systemic Genetic testing NCV/EMG Laboratory Imaging Biopsy ++ ++ Both sensory and motor fibers are affected in individual peripheral and cranial Anatomy/distribution nerves.