Toxidromes: A reminder!
Sympathomimetic: Agitated, mydriasis, febrile/tachy/HTN (wide pulse pressure), diaphoretic
E.g. Cocaine, amphetamines
Anticholinergic: Agitated, mydriasis, febrile/tachy/HTN, dry as a bone, red as a beet, mad as a hatter, urinary retention, decreased bowel sounds
E.g. Tricyclics, scopolamine, antihistamines
Cholinergic: Confusion/coma, miosis, brady, salivation, urinary/fecal incontinence, emesis, lacrimation
Opioid: CNS depression, miosis, hypothermia, brady, apnea, hyporeflexia
Sedative-hypnotic: CNS depression, hypothermia, brady, apnea, hyporeflexia
E.g. Benzos, barbiturates, alcohol, zolpidem
Hallucinogen: Hallucinations! Agitation, mydriasis, febrile/tachy/HTN, nystagmus
E.g. LSD, PCP, amphetamines
Atypical Multisystemic Bacterial Infections: Think the “3 Ellas!”
– Coxiella (Q Fever)
Atypical Pulmonary Bacterial Infections:
– Chlamydia pneumoniae
– Mycoplasma pneumoniae
– Legionella pneumophila
– Q Fever is far down the list!
Acute infection: self-limited, flu-like, pneumonia, or hepatitis. Incubation period = 2-5 weeks
Chronic (“persistent localized”) infection: Can follow acute or asymptomatic infection in 1-5% of patients. More likely in pregnant or immunocompromised patients, or underlying valvular/vascular disease or prosthetic joint.
- Endocarditis (most common!)
- Infected aneurysm or vascular graft
- Bone/joint infections
Primary exposure is farm animals or being downwind from a farm.
Dx with serologic testing (immunofluorescence), PCR if neg ab testing and high suspicion.
- C. burnetii does not grow in routine blood cultures!
All patients with acute Q fever should have TTE.
Tx for acute Q fever: Doxycycline x 14 days (reduces symptom duration)
- f/u testing at 3 and 6 months to confirm resolution
- TMP-SMX in pregnancy
- Treat for 1 year and add hydroxychloroquine if underlying valvulopathy or cardiomyopathy to prevent endocarditis!
Tx for persistent localized infection: Doxycycline + hydroxychloroquine x 18 months!
20% of patients develop post-Q fever fatigue syndrome, treatment is supportive.
Q fever vaccine? Effective in Australia, available in U.S. but not licensed (few human studies).