Physician Assistant
Board Review

This patient meets the diagnostic criteria for a hypomanic episode. Hypomania should be treated, even if it is associated with overfunctioning, because patients with hypomanic episodes are at risk for depression in the pattern of a depression/hypomania cycle. Current guidelines state that hypomania as well as mania should be treated with the same pharmacologic approach. Patients are likely to respond to the mood stabilizers lithium and valproate, as well as the second-generation antipsychotics olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole. It is also essential to verify that the patient has stopped taking any antidepressant medication or any other mania-inducing substances. Topiramate, lamotrigine, and gabapentin are not recommended for patients with mania or hypomania.

Reference:
Benazzi F. Bipolar II disorder: epidemiology, diagnosis and management. CNS Drugs. 2007;21(9):727-740.

U.S. Department of Veterans Affairs, U.S. Department of Defense, The Management of Bipolar Disorder Working Group. VA/DoD clinical practice guideline for management of bipolar disorder in adults. http://www.healthquality.va.gov/bipolar/bd_306_sum.pdf. Accessed November 14, 2012.

Educational Objective:

Recognize reactive arthritis.

Key Point:

Reactive arthritis presents with urethritis and, more recently, has been characterized by oligoarthritis, enthesitis of the Achilles tendon, conjunctivitis, and circinate balanitis.

Explanation:

This patient has a history of urethritis and recently developed oligoarthritis, enthesitis of the Achilles tendon, conjunctivitis, and circinate balanitis. This is a classical picture of reactive arthritis (formerly called Reiter syndrome).

The genital bacterium associated with reactive arthritis is C trachomatis. In patients infected with HIV, reactive arthritis is usually due to other agents, not HIV infection.

The enteric bacteria commonly associated with reactive arthritis include those from the genera Salmonella, Shigella, Yersinia, and Campylobacter. Clostridium difficile has also been associated with the condition.

References:

Marquez J, Restrepo CS, Candia L, Berman A, Espinoza LR. Human immunodeficiency virus-associated rheumatic disorders in the HAART era. J Rheumatol. 2004;31:741-746.

Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. 2008;59:113-121.

Educational Objective:

Recognize the manifestations of acne vulgaris.

Key Point:

Acne vulgaris is characterized by comedones, inflammatory papules, and pustules.

Explanation:

This patient has acne vulgaris, characterized by comedones, inflammatory papules, and pustules. Acne is not primarily an infectious skin disease, but rather is an inflammatory condition associated with sebaceous follicles, which are a specialized type of hair follicle on the face, chest, and back.

Rosacea is typically characterized by erythematous telangiectasias, papules/pustules, and phymas. This patient’s rash is not consistent with this diagnosis.

A furuncle is characterized by a painful, suppurative inflammatory nodule at the site of a hair follicle but is not associated with the comedones present in this case, making the diagnosis of furunculosis less likely.

Steroid-induced acne is less likely, because this patient does not have any history of steroid use. This type of acne is characterized by a monomorphous, inflammatory papular rash distinct from the polymorphous inflammatory papular appearance of acne vulgaris.

The classic rash associated with acute cutaneous lupus is described as an erythematous rash involving the cheeks and the bridge of the nose but sparing the nasolabial folds. This patient’s rash is not consistent with acute cutaneous lupus.

References:

Dahl M. Rosacea: pathogenesis, clinical features, and diagnosis. Revised January 23, 2017. Accessed June 7, 2017.

Downey K. Technique of incision and drainage for skin abscess. Revised May 16, 2017. Accessed June 7, 2017.

Merola J, Moschella S. Overview of cutaneous lupus erythematosus. Revised March 24, 2017. Accessed June 7, 2017.

Thiboutot D, Zaenglein A. Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris. Revised August 23, 2016. Accessed June 7, 2017.

Educational Objective:

Choose the appropriate pharmacologic treatment for a patient with peripheral vertigo.

Key Point:

Meclizine is an anticholinergic antihistamine used to treat Meniere disease and vestibular neuronitis. BPPV should not be treated with meclizine because its use may worsen symptoms and repositioning maneuvers are indicated. Benzodiazepines to treat vertigo should be avoided.

Explanation:

Meclizine is an anticholinergic antihistamine that can be used to treat Meniere disease and vestibular neuronitis, but it can worsen BPPV and is contraindicated in this disease. Pharmacologic treatments are not indicated for BPPV, which is treated with repositioning maneuvers.

Anticholinergic agents, particularly the lipophilic scopolamine, are also very effective and widely used for the symptomatic treatment of peripheral vertigo due to conditions such as viral neuronitis or labyrinthitis, and others, but not BPPV. Their main drawback is that they also cause sedation, although patients may be willing to tolerate this in the case of severe symptoms.

Phenothiazine antiemetics are also popular for symptomatic treatment, specifically for nausea and vomiting. They also possess some antihistamine and anticholinergic properties, which might also relieve some of the "spinning sensation" feeling. It is important to note that neither prochlorperazine nor chlorpromazine is an appropriate antiemetic for the treatment of vertigo, because they both also have significant alpha-adrenergic blocking abilities and will precipitate orthostatic symptoms even in young, healthy individuals, potentially worsening the dizziness; these drugs are also known to have other adverse effects.

Benzodiazepines are still widely prescribed for vertigo despite that the evidence is lacking of their efficacy. They are particularly dangerous in elderly patients who are already unsteady due to many other causes.

Patients with acoustic neuromas should be referred to an otolaryngologist for surgical consultation; medical therapy would not be effective for this condition.

References:

Furman J, Barton JJS. Treatment of vertigo. Updated August 2018. Accessed September 1, 2018.

Muncie HL, Sirmans SM, James E. Dizziness: approach to evaluation and management. Am Fam Physician. 2017;95:154-162.

Wipperman J. Dizziness and vertigo. In: Bope ET, Kellermen RD. Kellerman RD, Bope ET. Conn’s Current Therapy. 2018:8-11.

Mannitol is an osmotic diuretic that produces a water diuresis by its inhibition of sodium and water reabsorption in the proximal tubule and loop of Henle. If water losses are not replaces, it can lead to a free water deficit and hypernatremia. Lisinopril and nifedipine cause no clinical disturbance in sodium and water handling. Hydrochlorothiazide may lead to hyponatremia as the medullary gradient and an upregulation in water reabsorption in the cortical collecting duct occurs as a result of volume contraction. Spironolactone has its greatest effect on K handling in the distal nephron. In the setting of renal failure, however, mannitol is not filtered and cleared and can act as a strong osmolyte in the serum, leading the hyperosmolarity and a shift of water out of cells. This can cause a relative hyponatremia, but will only occur with renal failure.