Physician Assistant
Board Review

A paradox in GERD is that symptoms and endoscopic features poorly correlate. A total of 40% of people with Barrett’s esophagus report reflux symptoms, and one-third of those with esophagitis report reflux. When symptoms are typical and the patient responds well to therapy, no diagnostic tests are necessary to verify the diagnosis of GERD.

Reference:

Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328.

Educational Objective:

Characterize the presentation and management of infantile hemangioma.

Explanation:

Capillary hemangiomas develop early in life. In general, they will grow, remain stable, and involute spontaneously by the age of 5 years. Spontaneous involution often produces a better cosmetic result than excision.

Only when the hemangioma is obstructing a vital organ should immediate therapy be instituted. Propranolol is the drug of choice for rapidly growing hemangiomas that are compromising breathing or vision. Use of propranolol inhibits any further growth of the lesions and hastens involution. Propranolol is extremely effective and is now the preferred treatment of choice. Previously, Laser (pulsed dye) therapy or intralesional steroids were used.

References:

Martin K. Vascular disorders. In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 20th ed., 2015:3122-3128.

Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2013;131(1):128-140.

Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier J, et al. A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med. 2015;372(8):735-746.

Szychta P, Stewart K, Anderson W. Treatment of infantile hemangiomas with propranolol: clinical guidelines. Plast Reconstr Surg. 2014;133(4):852-862.

The main principles of antibiotic use in health care–associated pneumonia include the proper selection of antibiotics, de-escalation of initial therapy when possible, stopping antibiotics when there is a clinical response, and conducting further evaluation of patients who do not respond to treatment. The antibiotic dose should ensure that serum concentrations of the antibiotics remain above the minimum inhibitory concentration of the pathogen for as long as possible. Standard doses of antibiotics are formulated to achieve this concentration, while minimizing  drug toxicity. De-escalation of antibiotic therapy based on clinical response in 24-48 hours is appropriate, and data support limiting the duration of therapy to 7 days in responders who otherwise have no other complications.

The administration of antibiotics should not be delayed. The initial antibiotic regimen should not be altered because it may take 24-48 hours to elicit a clinical response.

Clinical deterioration may be due to choosing an inappropriate therapy, making an incorrect diagnosis, or targeting the wrong pathogen.

Reference:

Craven DE, Chroneou A. Nosocomial pneumonia. In: Mandell GL, et al, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed., 2010.

A relatively common cause of chronic pelvic pain is endometriosis whose hallmark is a cyclical relationship. Symptoms can mimic other types of pelvic pathology. Diagnosis is made by laparoscopy.

Reference:

Hart D. Lipsky A. Acute Pelvic Pain in Women (Chapter 33) in Marx: Rosen's Emergency Medicine, 8th ed.: 2014.

The best course of action in this patient with presumptive HSP is to provide supportive care with increased oral hydration and as-needed acetaminophen for pain control. Therapy with methotrexate/infliximab/cyclophosphamide is not indicated in this case. If the patient is unable to tolerate oral pills or take care of herself, then one could consider therapy with glucocorticoids to decrease the duration of abdominal pain, but doing so does not change the underlying disease process.

HSP is a vasculitis triggered by infections, medications, and other irritant exposures such as chemicals, insect bites, and even vaccinations. In most cases of HSP, the disease spontaneously resolves within 6 to 8 weeks without treatment and without sequelae, but fluctuations and recurrences over several months can occur. The most serious complication of HSP is persistent nephritis, which can lead to renal failure.

Steroids and cytotoxic agents are sometimes used as treatments, but their effectiveness is limited. Steroids relieve inflammatory symptoms of arthralgia and may prevent bowel intussusceptions, which occur infrequently, but they have little effect on nephritis or skin manifestations. Their use should be limited to patients presenting with serious gastrointestinal symptoms. HSP may occur at any age, but it is most common in children and young adults.

Migratory arthralgia and arthritis may be present, especially in the lower extremities. Hematuria due to renal vasculitis with glomerular crescents and immunoglobulin A mesangial deposits may occur.

Subsequently, symptoms can develop, of which the following are the most common:

• Rash (95%-100% of cases), especially involving the legs (the hallmark of the disease)
• Abdominal pain and vomiting (35%-85%)
• Joint pain (60%-84%), especially involving the knees and ankles
• Subcutaneous edema (20%-50%)
• Scrotal edema (2%-35%)
• Bloody stools

References:

Dedeoglu F, Kim S. Henoch-Schönlein purpura (immunoglobulin A vasculitis). Accessed March 30, 2016.

Duvuru G, et al. Henoch-Schönlein purpura. In: Imboden JB, et al, eds. Current Diagnosis & Treatment: Rheumatology. 3rd ed.,2013.

Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed., 2010.

Scheinfeld NS. Henoch-Schonlein purpura. Accessed March 30, 2016.