Is the answer always syphilis? (Le, 2021)

Thanks to Dr. Jimmy Le for an excellent Grand Rounds presentation this week on Syphilis. Rates of syphilis have been on the rise in the US and in Sonoma County for the last decade.

A recording of his excellent presentation is available HERE.

For those of you who want the notes, here are my notes:

Epidemiology:

• Before 2013, cases of syphilis in the US were generally concentrated in men who have sex with men (MSM) 
• From 2013-2018, there has been increase of 170% primary and secondary syphilis diagnosis in women AND rising rates in black/Latinx populations
• There is a high rate of co-infection w/HIV (42% MSM with syphilis also have HIV)
• In 2019, 129K cases of syphilis in the US (MSM and MSMW), 1870 cases reported of congenital syphilis (unfortunately more common in BIPOC mothers)
• In SoCo, as well, rates have been increasing, similarly transitioning from primarily a disease in MSM to a wider category of folks, including more women, homeless, persons who inject drugs

What is syphilis?

• A spirochete infection caused by treponema pallidum
• Multiple stages of syphilis can be confusing (see graphic below from Emory)
• The incubation period 9 days-3 months (can be asymptomatic)
• Neurosyphilis, ocular syphilis and otic syphilis can happen at ANY time during infection (should have low threshold to test for these)

Primary syphilis: 3-90 days after exposure, painless chancre, round and firm, can appear anywhere, generally 3 weeks after infection, heal on own in days/weeks, place where chancre appears is where exposure occurred (e.g. anus, vagina, penis). Gets missed, people don't notice because it doesn't hurt!

Secondary syphilis: 3-6 months after initial infection: "bigger rashes", more widespread (hands, feet, trunk, tongue, hair loss)

Tertiary syphilis: years to decades after exposure, "the great imitator", can show up in any tissues: cardiovascular, skin, bone, etc

Early latent: asymptomatic, <12 months of exposure

Late latent: asymptomatic  infection >12 months of exposure, "syphilis of unknown duration"

Neurosyphilis: CNS infection (meningitis), general paresis, tabes dorsalis

Ocular syphilis: vision loss, blurry vision, eye pain, redness

Otic syphilis: sensorineural hearing loss, tinnitus, vertigo

Transmission:

• Primary syphilis is VERY transmittable (lots of treponemes in primary chancres-- any surface is vulnerable), likelihood of transmission is ~30%
• As you move through stages, you become less and less infectious, can definitely still transmit but less than primary
• Syphilis is also one of TORCHES infections, the spirochete crosses the placenta very readily

Diagnosis:

• Two types of tests:
• Non-treponemal test: tests for cardiolipin cholesterol-lecithin antigen (RPR, VDRL), always presented as titers
• Treponemal test: detection of Ab against Ag. once positive, will always test positive (FTA-ABS, TPPA)
• Two methods for testing, decision which algorithm to use is based on prevalence. Generally thought higher prevalence area should use reverse testing algorithm 
• Traditional (see image) starts with RPR, reflex to TPPA confirmation
• Reverse (see image), do the opposite (start with TPPA), if that tests positive, reflexes to RPR)
• Once a patient is positive, Treponemal tests will ALWAYS be positive, so you always need RPR and titers
• Do note, you can have false negative RPR in latent period and upon appearance of chancre 1-3 weeks (e.g. if you are testing "too early", if you see a chancre, treat treat treat)
• Dx of neurosyphilis requires high clinical suspicion and low threshold for doing LP and getting CSF: test for protein, WBC, CSF-VDRL (which has poor sensitivity, 70% can test negative)

Treatment

Penicillin is ALWAYS the treatment (see chart above for details)

• Don't forget to get an RPR on the day of treatment (to get baseline)
• If a patient reports contact with anyone with syphilis in the last 90 days, treat empirically! 
• including partner treatment!
• www.dontspreadit.com (anonymous texting about exposure)
• Primary, secondary, early latent (<12 months): PCN 2.4 million units IMx 1
• Late latent (>12 months), unknown duration of tertiary with normal CSF: need to be treated with IM injections x 3 (one week apart)
• Neuro/ocular/otic syphilis: treatment is IV PCN 10-14 days (usually initial hospitalization)
• If a patient has PCN allergy, desensitization and treatment with PCN is still recommended (JAMA article on PCN desensitization available HERE)
• Follow-up testing is KEY: 
• for primary/secondary, early latent, retest with RPR at 6, 12 month (looking for 4x decrease in titer)
• for late latent, unknown, you should retest at 6, 12, and 24 months
• RPR baseline will be your guideline to determine if someone has been reinfected (4x increase demonstrates reinfection)

Questions about staging/treatment, can always call: Team Vida 707-583-8823 or SoCo Health Department 707-565-4566

Congenital Syphilis:

• complex diagnosis and treatment algorithms (see diagram from California DPH below)
• steady rise of congenital syphilis since 2012, 400% increase since 2012
• syphilis readily crosses placenta or via contact with chancre during delivery
• can affect ALL organs of the body, can lead to infant death and miscarriage
• wide clinical presentation: < 2 year old, usually presents by 5w-3 months of age, 60-90% will be symptomatic
• sx include hepatomegaly, jaundice, rhinitis ("snuffles"=white discharge, more severe than common cold, mucous discharge VERY infectious because lots of treponemes in them), rash, generalized LAD, skeletal abnormalities
• Treatment: IV PCN 50K units/kg q8 hours x 1 week, then q12 hours OR PCM IM x daily x 10 days
• Evaluation: neurodevelopmental, hearing, eye, serologic testing with RPR until negative or 4x decrease (usually non-reactive by 6 months)

https://californiaptc.com/in-the-news/new-tool-for-clinicians-unveiled-to-ensure-appropriate-treatment-of-congenital-syphilis/

Screen for STIs!

Screen all sexually active patients for HIV, RPR, GC/CT (including swabbing every site they use to have sex, including mouth, vagina, rectal)

Other STIs predict HIV risk (see infographic)

Offer partner treatment always

https://californiaptc.com/wp-content/uploads/2017/03/Slide7.jpg

Vomiting in Children (Mueller, 4/21/2021)

Many thanks to Dr. Claudia Mueller, Stanford and CPMC pediatric surgeon, for an excellent presentation on Vomiting in Children-- her lens, unsurprisingly, was on the surgical causes of vomiting in children. 

As a family medicine physician, I don't typically consider vomiting in children a "surgical" problem, but it was sure a good reminder that sometimes it is! It's a hearty crew of clinicians who want to assemble at 7:30am to talk about vomit-- but hey-I have to tell you-- her presentation was excellent!  AND the best part was that Dr. Mueller gave us a number to call if we ever run into problems. 

To watch Dr. Mueller's excellent presentation click HERE.

For the Cliff's notes version, here you go:

• Surgical causes of vomiting in children can rapidly progress to be life threatening
• Ask yourself How sick is this kid? Do they have fever, tachycardia, moist music membranes, lethargy? Can I get them to stand for the KUB?
• Presence of vomiting and ABSENCE of diarrhea is a concerning sign 
• This makes sense; most vomiting in kids is related to acute viral gastroenteritis or food poisoning, both of which should be accompanied by diarrhea. The absence of diarrhea is a sign that surgical causes of vomiting should be on your ddx
• The color of the vomit is key: color gives you some indication of the level the vomit is coming from (I know, I know, who wants to talk about the color of vomit) 
• this is particularly true in infants
• yellow/green (bilious) emesis in children <1 year is an "alarm bell that should be rung through the streets of any city" as it could be a surgical emergency (cardinal hallmark of a midgut volvulus that you do NOT want to miss)
• most children will vomit food and other particulate matter, if they vomit long enough, they will eventually vomit bile, so prolonged vomiting leading to bilious vomiting may be less concerning than it starting out bilious

• The intestine is a tube: in addition to the color of the vomit, what is coming out the bottom gives us a lot of information. If a child is having something out the bottom, they are much less likely to have true obstruction
• Passing gas is best indication (more even than bowel movements)

SBO

• Previous abdominal surgery is #1 cause of of adhesions causing SBO in children
• traumatic surgeries (e.g. trauma ex-lap) are more likely to lead to adhesions
• laparoscopic surgery maybe less risky (eg. laparoscopic appy) 
• Farting is a good sign-- air doesn't just hang out in the colon; a child that is passing gas, even if there is an obstruction, it is at least partial
• Be aware: not all kids with SBO get abdominal distention
• An UPRIGHT KUB is the imaging modality of choice to evaluate for SBO in a child
• want to be able to visualize: diaphragm, rectal gas
• UPRIGHT is super important: air goes to top, liquid down to the bottom
• air-fluid levels (straight lines) in SBO (can see in ileus, but more common in SBO)
• a sick child who cannot stand up for KUB is concerning
• CT scans can show more detail, e.g. the "point of the obstruction" but generally try to avoid CT scans in children <10 due to radiation
• if you do CT scan, should do IV contrast; used to always require oral contrast (and can be more helpful), but should be done carefully due to risk of aspiration 

Upright KUB showing SBO

• Initial treatment: NGT for decompression 
• NGT should be adequate size (if it's too small, won't work as well). An NGT an actually treat SBO by relieving the pressure
• Babies, size 10-12
• Toddlers, size 12-14
• age >7 years, size 14
• teenagers/adults, minimum size 14, better >16
• NGT has to be flushed, or it will get clogged
• If NGT is working, as evidenced by the amount coming out of NGT decreases, and child starts feeling better, you may be able to avoid surgery
• Another option after NGT: small bowel follow-through with gastrograffin (or ominpaque) can be diagnostic AND therapeutic
• 25-50cc, repeat KUB 6-12 hours after administration: decreases hospital stay either because quicker to OR vs. able to discharge home
• Hydration and serial abdominal exams are important in SBO

Midgut volvulus is the most urgent cause of bilious vomiting, usually in children <1 year old (85% before 6 months, 95% before 1 year)

• A true emergency is caused because mesenteric vein and artery get twisted, no blood flow to the entire small bowel (colon and first/second part of duodenum have their own blood supply)
• Can be life threatening in a few hours
• Perfectly healthy baby totally fine, suddenly starts throwing up yellow/green, call a surgeon!
• Imaging: UGI shows cutoff; x-ray may show just a stomach bubble (no other gas)
• Consequence so dire: lose entire small intestine, may never be able to survive not on TPN

Pyloric Stenosis typically thickening/hypertrophy of pyloric muscle fibers

• No one know why it happens
• Usually age 2 weeks to 2 months, classically first-born males
• Non-bilious (breastmilk or formula), progressive and persistent
• Imaging: ultrasound
• Surgery: cut open hypertrophic fibers, outer layer and spread it (pyloromyotomy)
• Typically does not recur

Appendicitis

• n/v, abdominal pain, umbilical down to RLQ
• renewed interest in conservative management with antibiotics only
• 95% of cases can be treated with antibiotics only, but 20% will recur in 1 year, 30% in 5 years
• fecolith has VERY high recurrence, should be operated lap appendectomy

Ileocolic intussusception

• generally age 6-36 months
• small part of small intestine gets stuck in large intestine
• usually due to laxity, lead point usually a lymph node, can be seen after enteritis OR after immunization (e.g. rotavirus vaccine)
• Imaging: ultrasound, "target sign"
• Reduction via radiology (air or contrast from anus into rectum, pushes the intussusception , reduces the small intestine), works large majority of time in kids without ischemia
• 10% recurrence rate-->  to OR
• Older kids need work up, lead point (e.g. lymphoma)

Hernias

• bilious vomiting, if incarcerated
• remember to take off vomiting baby's diaper to look for non-reduceable hernia

Dental Care for Primary Care (Gonzalez, 4/14/2021)

Great thanks and Happy Birthday to our Grand Rounds speaker this week, Gina Gonzalez, DDS for a comprehensive review of what primary care doctors should know about dental care: Oral Health for the Primary Care Provider. Dr. Gonzalez took us from the cradle to the grave (or crib to casket, so to speak) and motivated me to schedule a dental preventive visit ASAP! 

She reminded us that the mouth is an important part of the body, and when medical providers are seeing patients, we should definitely be examining their mouths, giving them preventive dental care recommendations, and screening for oral cancers. 

For those of you who missed it, a link to the video recording can be found HERE. For those of you who prefer the summary, here are my summary notes:

Tooth decay and periodontal disease are 100% preventable

• 92% of US adult have dental disease, 50% have gum disease, 5% of adults are edentulous
• 42% of US children have early childhood cavities (i.e. in baby teeth)
• Fluoride reduced decay by 50%

Pediatrics:

Prevention

• Cavities are an infectious disease! Strep mutans is the oral bacteria transmitted from adults' mouths to babies' mouths Pro tip: don't kiss babies on the mouth (you'll give them your bacteria)
• A baby's first visit to the dentist should be as soon as baby has its first tooth (parental education: how to care for the mouth, fluoride-- remember, in Sonoma County, we don't have fluoridated water, so parents need to use fluoride supplement or a fluoride containing toothpaste)
• To get a good look in a baby's mouth during your exam, try doing a knee-to-knee exam (see photo), in which the baby straddles parent and head is in examiner's lap 

  

  knee to knee dental exam position

  
  
• Kids should NOT use toothpaste unless they know to spit OR parents can put about 1/4 size of pea (can wipe away, is not harmful)
• Breastmilk (and formula ) both have a lot of carbs--> don't forget to wipe down baby's mouth after they feed
• Fruits and veggies that contain fluoride include: grapes, spinach, oatmeal and carrots
• Brush baby's teeth every day!
• Early childhood caries can be prevented: no fall asleep after nursing/bottle without wiping the teeth, only water in the bottle, clean
• No soda!

Pathology

• Rarely, infants are born with a neonatal tooth (often rudimentary root), which be easily extracted, particularly if they are making problems with breastfeeding
• Silver diamide fluoride is treatment for ECC (it may be ugly but STOPS the decay and avoids general anesthesia, capping, etc.)
• When a child is getting their adult teeth, two rows of teeth is normal, usually teeth come out on the own, don't worry!
• If a child's tooth comes out due to trauma, put the tooth back in child's mouth while you seek care; if you are worried they cannot safely do so, put the tooth in your own mouth (saliva is good for preserving the root). A third choice is to put it in milk (not water, which is dehydrating)
• In children, purulent abscess can form due to trauma or decay; if you see one, they critically need treatment 

Adults

Prevention

• Advise adults to floss their teeth before they brush: fluoride goes into cleaner space
• Power brushes can remove more plaque than traditional toothbrush
• Tongue hygiene brush is a good idea
• Drink water that is similar to pH of saliva (6.-7.6), bubbly water is acidic, saliva lubricates and bathes your teeth

Pathology

• Tooth decay is a result of poor hygiene, poor diet, genetics, prescription medications (e.g. SSRI, BP meds can cause a lot of dry mouth, leading to cervical decay--> add fluoride, brushing)
• soda is bad! 46gm sugar, very low pH
• Periodontitis is irreversible gum disease; it requires urgent and imperative tooth care
• As teeth decay and become abscess, infection can go through the bone, full of pus, hard to numb 
• As patients age, elders tend to drop out of routine care (transportation); don't forget to talk about how they are accessing dental care at well check visits
• Edentulism is a travesty! When teeth removed, you lose proprioception, start chewing funny, lose pressure to eat, get jaw collapse--> poor appetite, failure to thrive. Dental implants (with dentures attached) are superior!

Oral cancer screening is important and quick!

• grab a gauze, pull the tongue out!
• All you need: 2x2 gauze, tongue depressor and flashlight
• high risk locations for oral cancer: floor of the mouth, lateral borders of the tongue, junction of the hard and soft palate, and posterior oropharynx
• to do a cancer exam:
• look at skin of face, scaling, irregular and dark changes, particular attention to ear
• palpate back of neck, clavicular nodes, SCM, submandibular and sublingual glands
• eyes: Movement, melanoma, sclera
• look in nose
• look at vermillion border of mouth
• palpate bimanually to feel for anything fixed, parotid gland (tenderness occlusion), check joints (pops/clicks, jaw deviation)
  
• lateral border of tongue, floor of mouth, symmetry, gums/bones/teeth
• palpate inside mouth, junction of hard/soft palate
• look for symmetry!
• can be done in 3 minutes!
• oral cancer risks: tobacco, alcohol, vaping

Okay, now for a quiz: are these oral lesions benign or cancerous? Name these abnormalies (answers below)

A.

B.

C. 

D.

E.

F.

G.

H.

I.

J.

K.

A. black hairy tongue (benign) B. oral lichen planus C. Pyogenic granulomas (aka "pregnancy tumors") (benign) D. fordyce granules (benign) E. Geographic tongue (benign) F. Labial HSV G. Oral HPV H. Squamous cell cancer I. Squamous cell cancer  J. verrucous carcinoma K. precancerous lesion from snuff

Human Trafficking (Lisa Fatu, 4/7/2021)

Thanks to Lisa Fatu, director of Youth Crisis Services at Social Advocates for Youth (SAY), who spoke to us this week about Human Trafficking. A video recording of her presentation is available HERE. 

Human trafficking is the use of force, fraud or coercion to obtain some type of labor or commercial sex act; it is a multi-billion dollar international industry. Human trafficking can occur in any industry, including agriculture, construction, domestic service (housekeeper, nanny), restaurants, salons, commercial sex work, massage parlors, and small businesses. 

Between 2011 and 2018, the Sonoma County District Attorney pursued over 200 cases of human trafficking-- it is certain that many more were events were not reported. SAY provides crisis intervention, food, shelter, trauma-informed counseling, and much more. 

Lisa's goal for Grand Rounds was to teach health care providers how to keep our eyes out for victims of human trafficking-- recognizing that health care settings may be the only outside place where victims are allowed to be seen by their perpetrators. 

Things to look out for that may be indicative of a human trafficking situation:

• 80% of people trafficked are under 23 years old; average age 14
• Most victims are women, but men can also be trafficked
• Be suspicious if you see a young person with another female/male companion who is doing all the talking
• A trafficking victim may have their head down, make poor eye contact, make minimal interaction
• They may not know there address or have a PO Box (many traffickers take victims to clinics away from their home)
• They may not agree to be seen alone, don't want to be left in a room alone
• They may have bruises, burn markings, small cuts on the inner arm/feet (not generally visible without a full exam)
• They may have "branding tattoos" (e.g. behind ear, on neck)
• A victim may be coming only for a vaginal exam, but merit further questioning e.g. "Are you eating?"
• Victims may be particularly scare of needles

Lisa acknowledged that many of these "red flags" have overlap with insecure youth, youth who are inflicting their own self harm, a young person with poor self esteem, mail away brides, etc. Providers must use your judgement if you suspect the situation is not right, and take the next steps.

Things to consider:

• Educate your front desk employees (they are most likely to see who a patient arrives with, notice that they do not know their address, act oddly, etc)
• Always ask for a few moments alone with the patient, have their companion leave the room
• Consider having the patient leave a urine sample so you can see the patient away from the people that accompany him/her
• Have a game plan if you identify someone who you think is being trafficked
• Make relationships with local law enforcement (SRPD, SoCo sheriff's)
• Always make a follow-up appointment to give victim another chance to be offered services
• Consider having "nail cards" that have fake nail ad on them but actually have a phone # where help can be available

Aftercare

Unfortunately, 40% of human trafficking victims will return to their trafficker without intense intervention. Victims need therapy, safe living situations, wraparound services, money (they are used to having things paid for) and family education/services (consistency, monitoring relationships, internet activity, clothing)

Did you know SoCo has a multidisciplinary Human Trafficking Task Force?

For more information, contact lisa at: 707-546-3432 or lfatu@saysc.org

Or see SAY's website: https://www.saysc.org/

Nursing leadership at Sutter Santa Rosa Regional Hospital are currently working on a program to educate employees on Human Trafficking in our community. Let me know if you have questions/ideas. Thanks!

What a Pain! Tales of Adult Arthritides (Ramirez, 3/31/2021)

Thank you to Dr. Vanessa Ramirez for her review of two very important inflammatory arthritides at Grand Rounds this week: psoriatic arthritis and gout.  I gleaned so many important pearls from her presentation. For those of you interested in seeing the full recording, it is available here. My summary notes are below:

Inflammatory arthritides

• infectious (septic)
• crystal induced (gout, pseudogout)
• immune related (RA, SLE, psoriatic arthritis, dermatomyositis, Sjogren's)
• reactive

Psoriatic arthritis (PsA) 

• PsA affects about 20% of people with psoriasis 
• skin changes can precede arthritis sx for years-- even up to 12 years
• skin changes and PsA flares are not necessarily temporally related, nor is disease severity necessarily correlated
• typically asymmetric arthritis (in one, several or multiple joints), sacroiliitis (30-78%) 
• historic definition of PsA: serological negative (i.e. negative rheumatoid factor) polyarticular arthritis in someone with psoriasis skin manifestations
• classification Criteria for Psoriatic Arthritis (CASPAR) (2006) may be helpful in making this clinical diagnosis (see image below)
• early identification and treatment prevents joint destruction
• anti-CCP may be elevated (usually mild) in 12% of patients with PsA
• more likely in higher numbers of involved joints
• Risk factors for PsA
• scalp psoriasis 4x risk, intergluteal/perianal 2.3x risk, nail involvement
• earlier age at dx with psoriasis, >3 body sites affected, family hx of PsA (first degree)
• ESR is superior to CRP as a marker of damage progression and mortality
• Treatment for PSA includes lifestyle modification (diet, smoking cessation, exercise), followed by symptomatic treatments (NSAID, steroids, injections) and then TNF alphas
• see images below from the 2018 ACR Guidelines
• also see AAFP image, which includes cost of these treatments

2018 ACR Guidelines for Treatment of PsA

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

AAFP Psoriasis (Am Family Physician 2013)

https://www.aafp.org/afp/2013/0501/p626.html

Gout 

• Gout is caused by deposition of monosodium urate crystals in the joint space, periarticular structures and soft tissues
• associated with obesity, htn, hyperlipidemia, DM, CKD, heart failure, thiazide diuretic 
• ACR online tool Clinical prediction (see image)

• 

  https://www.aafp.org/afp/2020/1101/p533.html

  
  
  
• Treatment Acute
• 2020 ACR Guidelines for Treatment of Gout Flare
• Naproxen 500 mg BID OR indomethacin 50 mg TID, ibuprofen 800mg TID
• Colchicine (low dose) 1.2mg PO, then 0.6mg 1 hour later, then BID until flare resolves
• Oral prednisone 0.5mg/kg (5-10 days full dose then stop OR 2-5 days full dose and then taper over 7-10 days)
• Treatment Chronic
• all patients with tophi, radiographic evidence or damage or 2+ flares/year
• goal is symptom relief AND maintenance of urate levels (<6)
• we should be titrating allopurinol based on checking uric acid levels
• Allopurinol is treatment of choice, lower doses preferred to start
• if on thiazide for BP, switch to losartan