Oral symptoms of systemic diseases - what to suspect?

Examination of the oral cavity (mouth) may reveal findings pointing to an underlying systemic condition, and allow for early diagnosis and treatment.

Oral examination should include evaluation for:

- mucosal changes

- periodontal inflammation and bleeding

- condition of the teeth

Examples of lesions:

- Oral findings of anemia may include mucosal pallor, atrophic glossitis, and candidiasis.

- Oral ulceration may be found in patients with lupus erythematosus (SLE), pemphigus vulgaris, or Crohn disease. Oral manifestations of lupus erythematosus may include honeycomb plaques (silvery white, scarred plaques); raised keratotic plaques (verrucous lupus erythematosus); erythema, purpura, petechiae, and cheilitis.

Oral findings in patients with Crohn disease may include diffuse mucosal swelling, cobblestone mucosa, and localized mucogingivitis.

- Diffuse melanin pigmentation may be an early manifestation of Addison disease.

- Periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus (HIV) infection, thrombocytopenia, and leukemia.

- In patients with gastroesophageal reflux disease (GERD), bulimia, or anorexia, exposure of tooth enamel to acidic gastric contents may cause irreversible dental erosion. Severe erosion may require dental restoration. 

- In patients with pemphigus vulgaris, thrombocytopenia, or Crohn disease, oral changes may be the first sign of disease.

References:

Oral manifestations of systemic disease. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Am Fam Physician. 2010 Dec 1;82(11):1381-8.
Image source: Head and neck. Wikipedia, public domain.

Guidelines for Management of Acute Bacterial Sinusitis by Infectious Diseases Society of America

A bacterial cause accounts for 2%-10% of acute rhinosinusitis cases.


Nose and nasal cavities. Image source: Wikipedia, public domain.

Recommendations for Management of Acute Bacterial Sinusitis by the Infectious Diseases Society of America (IDSA):

Bacterial rather than viral rhinosinusitis should be diagnosed when any of the following occurs:

- persistent symptoms lasting at least 10 days, without improvement
- symptoms or high fever and purulent nasal discharge or facial pain for 3–4 days at illness onset
- worsening symptoms after an initial respiratory infection, lasting 5–6 days, has started to improve.

Empirical therapy should be started as soon as acute bacterial rhinosinusitis is diagnosed clinically.

Amoxicillin-clavulanate, instead of amoxicillin alone, is recommended for both children and adults.

Macrolides and trimethoprim-sulfamethoxazole are not recommended as empirical therapy, because of high rates of antimicrobial resistance.

References:

Algorithm for the management of acute bacterial rhinosinusitis (figure)
Guideline Issued for Managing Acute Bacterial Rhinosinusitis - Physician's First Watch http://bit.ly/TGn6aM
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults http://bit.ly/TGnaHB

The men behind famous eponymous diseases

From CNN:

"Having a disease named after you is a decidedly mixed bag. On the one hand, your scientific developments are forever commemorated. On the other hand, though, you're stuck with the knowledge that no patient will ever be happy upon hearing your name."

Daniel Elmer Salmon (1850 – 1914) was a veterinary surgeon. He earned the first D.V.M. degree awarded in the United States, and spent his career studying animal diseases for the U.S. Department of Agriculture. He gave his name to the Salmonella genus of bacteria, which were discovered by an assistant, and named in his honor. Image source: Wikipedia, public domain.

New medical conditions that are being discovered are not named after scientists or physicians anymore. The eponymous system is non-descriptive and generally confusing.

References:

The men behind famous diseases. CNN.

What's new in infectious diseases from UpToDate

- Brain MRI may be useful in patients with endocarditis. In one study including 53 patients, early use of cerebral MRI led to the reclassification from possible to definite IE in 30% of cases.

Figure 1. TEE shows AV Endocarditis in a patient with IVDA. There is a large vegetation on the aortic valve with 2-3+ AI (click to enlarge the image). Source: Double Hit – Right and Left-Sided Endocarditis in a Heroin Abuser.

- Cotrimoxazole prophylaxis was associated with a 50 percent reduction in deaths in patients starting antiretroviral therapy with CD4 counts lower than 200 cells.

- Universal influenza immunization: In 2010, the CDC expanded the recommendation for influenza vaccination to include all individuals 6 months of age and older. Previous guidelines recommended influenza vaccination for individuals over age 50 and for those at increased risk of influenza complications and close contacts of such individuals.

How to Subscribe to "What's New" Specialty Page of UpToDate? No Feed, No Problem for Google Reader

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page.

The page does not provide RSS feed for the different specialties. One solution is to copy/paste the URL address of each subspecialty page you are interested in the Google Reader "Add a subscription" field (top left corner). Google Reader will automatically create a RSS feed from this "feedless" page.

References:
What's new in infectious diseases. UpToDate, 2010.

UTD Contents: What's New

Are You Dependent on UpToDate for Your Clinical Practice?
5 Tips to Stay Up-to-Date with Medical Literature

Acupuncture can spread serious diseases: bacterial infections, hepatitis B and C, even HIV

To prevent infections transmitted by acupuncture, infection control measures should be implemented, such as use of disposable needles, skin disinfection procedures and aseptic techniques.

Acupuncture may be risky as needles are inserted up to several centimeters beneath the skin. In the 1970s and 1980s most infections associated with acupuncture were sporadic cases involving pyogenic bacteria.

There is a new syndrome - acupuncture mycobacteriosis - infection caused by mycobacteria that rapidly grow around the acupuncture insertion point as a result of contaminated cotton wool swabs, towels and hot-pack covers. There is a long incubation period and the infection usually leads to large abscesses and ulcers.

References:

Acupuncture transmitted infections. BMJ 2010;340:c1268.

Acupuncture can spread serious diseases: experts. Reuters.
Does traditional Chinese medicine have a place in the health system? http://goo.gl/RH04o

Image source: Needles being inserted into a patient's skin, Wikipedia, public domain.

Osteoporosis Drug Lasofoxifene May "Fight" Several Diseases But Increases Risk of Blood Clots

Lasofoxifene is a part of a class of drugs known as nonsteroidal selective estrogen-receptor modulators (SERMs). It has already been shown to decrease the bone loss associated with osteoporosis, like other SERMs, including tamoxifen and raloxifene. But until now its effect on other health conditions commonly experienced by postmenopausal women was unknown.

The women who took lasofoxifene had an 81% lower risk of estrogen-receptor (ER) positive breast cancer, a 32% lower risk of heart-related events like heart attack, and a 36% lower risk of stroke. "This is the first SERM that reduces the risk of all of these conditions at once."

However, not all the results were positive. As with other SERMs, women taking lasofoxifene had double to nearly three times the risk of experiencing a serious blot clot of the deep veins.

References:
Osteoporosis Drug May Fight Several Diseases. WebMD, 2010.

NEJM -- Lasofoxifene in Postmenopausal Women with Osteoporosis.

Image source: Flickr, Creative Commons license.