After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test.

A 35-year-old woman referred to the emergency department for head trauma due to a fall on a scooter, with no loss of consciousness or amnesia. The examination shows a closed head injury with concussion and mild headache without nausea and vomiting. The neurological examination is normal and the Glasgow index is 15. In this situation, which imaging test is indicated first?

[Indications for computed tomography in patients with mild head injuries].

To identify clinical parameters that may be associated with intracranial lesions in patients with mild head injuries, Glasgow Coma Scale (GCS) scores of 15 but without any focal neurological deficit. All head trauma patients admitted to the emergency room within 3 months with GCS scores of 15 (n = 371) were evaluated. Patients with focal neurological deficits, penetrating or multiple traumas, gun shot wounds were not evaluated. Mean age of 222 male and 149 female patients was 22.4 years. Frequency of intracranial lesions detected in CT was higher in patients older than 60 years of age. A significant difference was not found between both genders. Detection rate of abnormalities was higher after motorway accidents. Loss of consciousness and post-traumatic fits were associated with higher rates of pathological sequelae. A significant difference was not found between patients with or without headache, nausea, and vomiting. Sensitivity and specificity of cranial x-ray were estimated to be 38.2% and 93.2% when compared with cranial CT respectively. The incidence of intracranial lesions in patients with mild head injuries, GCS scores of 15, younger than 60 years of age, and without any focal neurological deficits, loss of consciousness, post-traumatic fits, gun shot wound, and penetrating injury is 0.6%.

Prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma.

The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities. In patients with mild head injury (Glasgow Coma Scale score = 13-15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms. This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings. The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive. Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40-45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury.

Minor head trauma: Is computed tomography always necessary?

To determine the clinical value of routine computed tomography (CT) of the head in patients with normal mental status after minor head trauma. We carried out a prospective study of a consecutive series of patients of all ages who presented to our urban university Level I trauma center emergency department with a Glasgow Coma Scale score of 15 and underwent CT of the head after loss of consciousness (LOC) or amnesia to event. A data form was filled out for each patient before CT. Patients with abnormal CT results were followed to discharge. We analyzed data with the chi 2 and student t tests. Of 1,382 patients, traumatic intracranial abnormality was identified on CT of the head in 84 (6.1%). Three patients in this group (.2%) required surgery. The subgroup of patients with history of LOC/amnesia but no symptoms or signs of a depressed skull fracture had a rate of abnormal CT findings of only 3% (24 of 789), and no patient in this group required medical or surgical intervention. Nausea and vomiting and signs of head trauma were significantly more common in the group with abnormal CT findings. Routine CT of the head in patients with history of LOC/amnesia but no symptoms or signs of depressed skull fracture has minimal clinical value and is not warranted. Patients with symptoms of head injury or apparent depressed skull fracture should undergo head CT because a small number will require surgery.

Mild head injury: revisited.

1. To define the incidence of positive CT scans in patients with different grades of mild head injury (MHI), 2. To identify clinical predictors of positive CT scans, 3. To evaluate the usefulness of plain radiographs in the triage of patients with MHI, 4. To evaluate frequency and nature of surgical intervention in MHI, 5. To evaluate the risk of deterioration in MHI, and 6. To find out whether patients with normal neurological examination and normal CT can be safely discharged. In a prospective study conducted over a period of four months in our center, all patients with mild head injury (defined as Glasgow Coma Scores (GCS) 13-15) were admitted to the head injury unit. Patients underwent standard clinical examination, skull radiography and cranial CT. No clinical criteria were used to select patients for CT scanning and all the patients were subjected to CT. Patients with negative findings on CT and a normal neurological examination were discharged after 24 hours of observation. Patients with positive findings on cranial CT were treated either medically or surgically as deemed necessary. Outcome measures included safe discharge, clinical deterioration, need for surgical intervention or death. The following factors were analyzed statistically to find out whether they can be used as predictive factors for positive cranial CT. They were: age, sex, mode of injury, loss of consciousness, post-traumatic seizures, ear/ nose/throat bleeding, vomiting, admission GCS score, scalp injury, polytrauma, focal neurological deficit, fractures visualized on skull radiography. Three hundred and eighty one patients were included in the study. Of these males constituted 63%, females 17% and children 20%. RTA was the most common mode of injury. Seventy five percent of the patients had GCS of 15, 15% had GCS of 14 and 10% had GCS of 13. Thirty eight percent of the patients had positive findings on the CT. Age, mode of injury, loss of consciousness, post-traumatic seizures, ENT bleeding, vomiting, scalp injury and polytrauma were not found to be predictors of positive CT. Admission GCS score, focal neurological deficits, and fractures detected by skull radiography were found to be statistically significant predictors of positive findings on CT. Seven percent of patients required surgical intervention. Six percent of patients showed neurological deterioration and there was one death in this series of MHI patients. Patients with multiple lesions on CT had a higher chance of deterioration than those with a single lesion. No patient who had a GCS of 15 and normal CT developed any complication during the hospital stay or after discharge. The incidence of positive CT scans in this prospective, consecutive, unselected cohort of MHI patients was 38%. Lower admission GCS scores, focal neurological deficits, and fractures detected by skull x-rays were found to be significant predictors of positive CT. Other clinical parameters were not found to be predictors of positive CT. CT was found to be superior to plain x-rays in detecting skull fractures. Seven percent of this cohort required neurosurgical intervention. Six percent showed neurological deterioration and there was one death in this series. Patients with multiple lesions on CT had a higher chance of deterioration than those with single lesions. The duration of hospital stay was prolonged in patients with positive CT. As no patient with a normal neurological examination and a normal CT deteriorated, we believe these patients can be safely discharged without need for admission and observation.

Loss of consciousness: when to perform computed tomography?

To determine the diagnostic value of physical examination (including neurologic exam) for positive computed tomography scan findings in children with closed head injury, Glasgow Coma Scale score 13-15 in the emergency department, and loss of consciousness or amnesia. Prospective descriptive study. A large, tertiary, pediatric trauma center in San Diego County. Children ages 2-16 with an isolated closed head injury, history of loss of consciousness or amnesia, and Glasgow Coma Scale 13-15 who were referred for pediatric trauma evaluation and received a head computed tomography as part of this evaluation. A standardized physical examination including skull/scalp exam, pupils, tympanic membrane, and brief neurologic exam was documented on each patient. Subjects age 2-16 being evaluated by the pediatric trauma team for closed head injury with loss of consciousness or amnesia and Glasgow Coma Scale 13-15 received a standardized physical exam, noncontrast head computed tomography scan, and follow-up telephone call at 4-6 wks. Outcome variables include intracranial injury visualized on computed tomography scan and need for neurosurgical intervention. Ninety-eight subjects were enrolled in the study over a 1-yr period. Computed tomography scans revealed evidence of intracranial injury in 13 of 98 subjects (13%). Normal examination increased the probability of a normal computed tomography scan from.87 pretest to.90 posttest. Four of 38 subjects with normal examination were noted to have evidence of intracranial injury on computed tomography. These four subjects did not require neurosurgical intervention. Two of 98 subjects underwent neurosurgical procedures. One intracranial pressure monitor was placed for decreasing level of consciousness. One subject underwent surgical elevation of a depressed skull fracture. Detailed clinical examination is of no diagnostic value in detecting intracranial injuries found on head computed tomography scan. Patients with observed loss of consciousness or amnesia and Glasgow Coma Scale 13-15 should have a head computed tomography scan as part of their evaluation to avoid missing an intracranial injury.

Limitations of neurological assessment in mild head injury.

The authors have investigated two commonly used methods of assessing neurological status in patients with mild head injury to determine whether they can predict intracranial damage. Of 686 such patients with cranial computed tomography (CT) scans, scan results were recorded, along with total and motor components of the Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85). Despite relatively normal admission neurological examinations, 127 of the 689 patients (18.4%) had intracranial lesions, and 38 (5.5%) required surgery. There was no significant difference in distribution of the GCS in patients with and without intracranial lesions. The RLS85 was superior to the GCS in predicting intracranial pathology, and a significant association between RLS85 and lesions on CT scanning was noted. However, even this test was normal in 19 patients found to have intracranial pathology, including nine who required surgery. The authors conclude that a normal or near-normal mental status examination in a head-injured patient on arrival at the emergency room is inadequate to exclude a potentially serious intracranial lesion. It is unlikely that further refinements in the clinical evaluation will result in diagnostic accuracy comparable with that of CT scanning. Accordingly, we recommend that any patient who has suffered a loss of consciousness or amnesia following head injury have an urgent cranial CT scan.

Indications for brain CT scan in patients with minor head injury.

Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury. A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals. Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan. Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.

The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.

Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P > 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs < 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children.

Indications for brain computed tomography scan after minor head injury.

Minor head injury (MHI) is a common injury seen in Emergency Departments (ED). Computed tomography (CT) scan of the brain is a good method of investigation to diagnose intracranial lesions, but there is a disagreement about indications in MHI patients. We surveyed the post-traumatic symptoms, signs or past historical matters that can be used for the indication of brain CT scan. All patients with MHI who were older than 2 years, had a Glasgow Coma Scale (GCS) score ≥13 and were referred to the ED, underwent brain CT scan. Data on age, headache, vomiting, loss of consciousness (LOC) or amnesia, post-traumatic seizure, physical evidence of trauma above the clavicles, alcohol intoxication, and anticoagulant usage were collected. The main outcome measure was the presence of lesions related to the trauma in brain CT scan. For categorical variables, Chi-square test was used. Six hundred and forty-two patients were examined by brain CT scan after MHI, and 388 patients (60.4%) did not have any risk indicator. Twenty patients (3.1%) had abnormal brain CT scans. The logistic regression model showed that headache (P=0.006), LOC or amnesia (P=0.024) and alcohol (P=0.036) were associated with abnormal brain CT. WE SUGGESTED THAT ABNORMAL BRAIN CT SCAN RELATED TO THE TRAUMA AFTER MHI CAN BE PREDICTED BY THE PRESENCE OF ONE OR MORE OF THE FOLLOWING RISK INDICATORS: Headache, vomiting, LOC or amnesia, and alcohol intoxication. Thus, if any patient has these indicators following MHI, he must be considered as a high-risk MHI.

Risk factors indicating the need for cranial CT scans in elderly patients with head trauma: an Austrian trial and comparison with the Canadian CT Head Rule.

This study presents newly defined risk factors for detecting clinically important brain injury requiring neurosurgical intervention and intensive care, and compares it with the Canadian CT Head Rule (CCHR). This prospective cohort study was conducted in a single Austrian Level-I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department with witnessed loss of consciousness, disorientation, or amnesia, and a Glasgow Coma Scale (GCS) score of 13-15. The studied population consisted of a large number of elderly patients living in Vienna. The aim of the study was to investigate risk factors that help to predict the need for immediate cranial CT in patients with mild head trauma. Among the 12,786 enrolled patients, 1307 received a cranial CT scan. Four hundred eighty-nine patients (37.4%) with a mean age of 63.9 ± 22.8 years had evidence of an acute traumatic intracranial lesion on CT. Three patients (< 0.1%) were admitted to the intensive care unit for neurological observation and received oropharyngeal intubation. Seventeen patients (0.1%) underwent neurosurgical intervention. In 818 patients (62.6%), no evidence of an acute trauma-related lesion was found on CT. Data analysis showed that the presence of at least 1 of the following factors can predict the necessity of cranial CT: amnesia, GCS score, age > 65 years, loss of consciousness, nausea or vomiting, hypocoagulation, dementia or a history of ischemic stroke, anisocoria, skull fracture, and development of a focal neurological deficit. Patients requiring neurosurgical intervention were detected with a sensitivity of 90% and a specificity of 67% by using the authors' analysis. In contrast, the use of the CCHR in these patients detected the need for neurosurgical intervention with a sensitivity of only 80% and a specificity of 72%. The use of the suggested parameters proved to be superior in the detection of high-risk patients who sustained a mild head trauma compared with the CCHR rules. Further validation of these results in a multicenter setting is needed. Clinical trial registration no.: NCT00451789 ( ClinicalTrials.gov .).

Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury.

A retrospective review of 373 adult patients admitted to Harbor General Hospital between 1980 and 1984 for minor closed head injury (Glasgow coma scale 13-15) was performed to determine the benefits of skull radiography, computed tomographic (CT) scanning of the head, and admission for observation. Variables reviewed were mental status, neurological examination, presence or absence of loss of consciousness, clinical evidence of basilar skull fracture, and fracture on skull radiography. The neurological examination (including mental status and Glasgow coma scale) in the emergency room was the best predictor of subsequent deterioration or the presence of an operative hematoma. The only patients with Glasgow coma scale scores of 15 who required surgical evacuation of an extraaxial hematoma had focal neurological deficits referable to hemispheric compression, with or without an abnormal mental status. A Glasgow coma scale score of 13 or 14 places the patient at risk either of having a hematoma requiring surgery or of deteriorating. We recommend that a head CT scan be obtained on all patients with Glasgow coma scale scores of less than 15, abnormal mental status, or hemispheric neurological deficits. If no operative lesion is found on the CT scan, the patient should be admitted for observation because there is still a risk of deterioration. Those with a Glasgow coma scale score of 15, a normal mental status, and no hemispheric neurological deficit may be discharged to be observed at home by a competent observer despite basilar or calvarial skull fracture, loss of consciousness, or cranial nerve deficit. No benefit was gained from skull radiography in any group.

Sports-related traumatic brain injury

Case study example History: The individual is possibly unconscious when examined by medical personnel on the field. A common symptom is prolonged unconsciousness (coma), however this player reports headache, dizziness, nausea, vomiting, and weakness of the extremities (paresis) and makes inappropriate responses to questions. Physical exam: The individual's level of consciousness is disturbed. A neurological examination may not reveal any localizing signs. The individual with no other serious injuries than cerebral contusion will not have a fractured skull or any signs of opening or penetration of the skull. Tests: Skull x-rays check for a fracture. CT or MRI detect any bleeding in the skull. The Glasgow Coma Scale classifies the severity of brain injury, with a score of 15 as normal and progressively lower scores indicating greater neurologic injury to the brain.

An assessment of clinical predictors of intracranial head injury identified by computed tomography scan.

A prospective study was done during a six-month period on 104 consecutive patients who were seen at the Accident and Emergency (A&E) Department of the UHWI and referred for CT scans of the head within 24 hours of sustaining head injuries. There were 74 (71.1%) males and 30 (28.8%) females. The mean age for females was 40.6 years and 32.4 years for males. Patients were clinically assessed for the presence or absence of vomiting, amnesia, loss of consciousness, bleeding of ear, nose and throat (ENT) and Glasgow Coma score (GCS). Negative predictive values were calculated for each parameter individually as well as the combination of all five. The absence of vomiting, amnesia, "loss of consciousness" (LOC) or ENT bleed had negative predictive values of 68%, 73%, 76% and 61.6% respectively. An assessment of Glasgow Coma Scale (GCS) of 15 had a 77.5% negative predictive value. When the history was indeterminate, the negative predictive values were 19%, 25%, 60% and 18% respectively for vomiting, amnesia, LOC and ENT bleed. When all four clinical indicators were absent in the history and examination and the GCS score 15, the negative predictive value for intracranial injury was 89.4%. In summary, the clinical indicators reviewed, alone or in combination, cannot exclude the presence of intracranial injury.

[The role of computed tomography for minor head injury].

Head trauma is a major health problem which affects young people, especially young males and also causes serious economic losses. Although major head injuries are cause greater morbidity and mortality, minor head injuries are more common presentations to emergency departments. In this study our goal is to determine the prevalence of CT usage in minor, adult head injury patients and determine clinical variables for the use of head CT scans. In our study we retrospectively examined 230 adult head injury patients who were presented to the Dokuz Eylül University Medical School Hospital Emergency Department. We recorded age, gender, symptoms of nausea, vomiting, headache, alcohol use, physical examination findings, history of loss of consciousness prior to presentation, concurrent injuries, and Glasgow Coma Scale (GCS) scores. Head CT ordering and abnormal findings were correlated with the above clinical variables. We ascertained that all variables affected the ordering of CT scans except age, gender and alcohol use. The prevalence of abnormal head CT in all patients were 21.7%. We found that GCS is only one clinical variability of which statistically significant relationship to acquaint abnormal CT findings.

Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?: The Rational Clinical Examination Systematic Review.

Adults with apparently minor head trauma (Glasgow Coma Scale [GCS] scores ≥13 who appear well on examination) may have severe intracranial injuries requiring prompt intervention. Findings from clinical examination can aid in determining which adults with minor trauma have severe intracranial injuries visible on computed tomography (CT). To assess systematically the accuracy of symptoms and signs in adults with minor head trauma in order to identify those with severe intracranial injuries. We performed a systematic search of MEDLINE (1966-2015) and the Cochrane Library to identify studies assessing the diagnosis of intracranial injuries. Studies were included that measured the performance of findings for identifying intracranial injury with a reference standard of neuroimaging or follow-up evaluation. Fourteen studies (range, 431-7955 patients) met inclusion criteria with patients having GCS scores between 13 and 15 and 50% or more older than 18 years. Three authors independently performed critical appraisal and data extraction. The prevalence of severe intracranial injury (requiring prompt intervention) among the 23,079 patients with minor head trauma was 7.1% (95% CI, 6.8%-7.4%) and the prevalence of injuries leading to death or requiring neurosurgical intervention was 0.9% (95% CI, 0.78%-1.0%). The presence of physical examination findings suggestive of skull fracture (likelihood ratio [LR], 16; 95% CI, 3.1-59; specificity, 99%), GCS score of 13 (LR, 4.9; 95% CI, 2.8-8.5; specificity, 97%), 2 or more vomiting episodes (LR, 3.6; 95% CI, 3.1-4.1; specificity, 92%), any decline in GCS score (LR range, 3.4-16; specificity range, 91%-99%;), and pedestrians struck by motor vehicles (LR range, 3.0-4.3; specificity range, 96%-97%) were associated with severe intracranial injury on CT. Among patients with apparent minor head trauma, the absence of any of the features of the Canadian CT Head Rule (≥65 years; ≥2 vomiting episodes, amnesia >30 minutes, pedestrian struck, ejected from vehicle, fall >1 m, suspected skull fracture, or GCS score <15 at 2 hours) had an LR of 0.04 (95% CI, 0-0.65), lowering the probability of severe injury to 0.31% (95% CI, 0%-4.7%). The absence of all the New Orleans Criteria findings (>60 years, intoxication, headache, vomiting, amnesia, seizure, or trauma above the clavicle) had an LR of 0.08 (95% CI, 0.01-0.84), lowering the probability of severe intracranial injury to 0.61% (95% CI, 0.08%-6.0%). Combinations of history and physical examination features in clinical decision rules can identify patients with minor head trauma at low risk of severe intracranial injuries. Certain findings, including signs of skull fracture, GCS score of 13, 2 or more vomiting episodes, decrease in GCS score, and pedestrians struck by motor vehicles, may help identify patients at increased risk of severe intracranial injuries.

Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury.

Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.

Repeat CT after blunt head trauma and Glasgow Coma Scale score 13-15 without neurological deterioration is very low yield for intervention.

Due to the increase in accessibility of computed tomography (CT), repeat head CT scans are routinely ordered for patients with minor head injuries. The aim of this study is to evaluate the necessity and outcomes of routine repeat head CT in patients with GCS score of 13-15 who presented to the emergency department (ED) of Antalya University Hospital in Turkey with blunt head trauma. We retrospectively reviewed the charts of patients with minor head trauma that received initial and repeat head CT results from July 1, 2013 to June 30, 2015. Clinical characteristics of patients were compared for two groups of patients: those with neurological deterioration, and those who had routine head CT not required by change in neurological status. Repeat head CT results were analyzed for radiological worsening and the necessity of a surgical or medical intervention such as craniotomy, ICP monitoring, VP shunt and mannitol or hypertonic saline administration. Of 3578 patients with blunt head trauma, 656 (18.3%) patients had repeat head CT; 449 of these (68.4%) had a GCS score of 13-15. We analyzed 441 patients for CT and clinical changes. Eight patients were excluded because of poor image quality and/or penetrating injury. Neurological deterioration was the reason for repeat head CT in 73 (16.5%) patients Rates of medical (mannitol treatment) or surgical (craniotomy) intervention in this group were 26% (95% Confidence Interval [95% CI], 15.7-36.3%) in contrast to 0.8% (95% CI 0.1-1.7%) in the group of patients with routinely ordered head CT but without clinical deterioration. The following factors were statistically associated with need for intervention: use of anticoagulant or antithrombotic medication, fracture in middle meningeal artery territory, even a single point decrease in GCS score, increased headache, recurrent vomiting, neurological deficit, and finally, changes in repeat head CT. In patients with minor head injuries, those without neurological deterioration have a very low risk of need for medical or surgical intervention. Routinely ordering repeat head CT scans in this group may not be routinely indicated.

Concussion

If the Glasgow coma scale is less than 15 at two hours or less than 14 at any time, a CT is recommended. In addition, a CT scan is more likely to be performed if observation after discharge is not assured or intoxication is present, there is suspected increased risk for bleeding, age greater than 60, or less than 16. Most concussions, without complication, cannot be detected with MRI or CT scans. However, changes have been reported on MRI and SPECT imaging in those with concussion and normal CT scans, and post-concussion syndrome may be associated with abnormalities visible on SPECT and PET scans. Mild head injury may or may not produce abnormal EEG readings. A blood test known as the Brain Trauma Indicator was approved in the United States in 2018 and may be able to rule out the risk of intracranial bleeding and thus the need for a CT scan for adults.

Mild head injury: differences in prognosis among patients with a Glasgow Coma Scale score of 13 to 15 and analysis of factors associated with abnormal CT findings.

We performed a retrospective study of 2484 consecutive patients with mild head injury (Glasgow Coma Scale score 13-15) who were seen during a period of 18 months. Of these, 2351 (94.6%) patients scored 15 points, 88 (3.5%) scored 14 points and 45 (1.3%) 13 points. A multivariate analysis showed that advanced age, a lower GCS (13-14) and the presence of skull fracture, and focal signs, significantly increased the incidence of abnormal computed tomography (CT) findings. By contrast, the gender, the mechanism of injury, the occurrence of initial loss of consciousness, posttraumatic amnesia and coagulation disorders did not significantly increase the incidence of abnormal CT findings. Patients with 13-14 GCS had a significantly higher incidence of initial loss of consciousness, of skull fracture, abnormal CT findings, need for hospital admission, delayed neurological deterioration and need for operation than patients with a GCS of 15. Thus, we suggest separating patients with a GCS of 13-14 into a different category and recommend performing CT in all those not improving within 4-6 h of injury. Such a policy makes skull radiography unnecessary in this subgroup. By contrast, skull radiographs may be useful for the triage of patients with a GCS of 15 that represent most of the mild head injury cases; radiographs should be obtained in patients presenting with initial loss of consciousness or posttraumatic amnesia (27.9% of the total cases) as these two findings were associated with a significantly higher incidence of fracture. Patients without these two findings (72.1% of the cases) showed a very low incidence of skull fracture (0.9% in this study) and may be discharged home with a warning sheet.

[The risk of an organic lesion in mild craniocerebral injuries with loss of consciousness].

Despite its high frequency, there is not a consensus for the management of a patient with mild head trauma. In this prospective study we analyzed wether the transient loss of consciousness was associated with a higher risk of cranioencephalic injury in function of patient's age. Fifty-two patients with a Glasgow score of 15 at the Emergency Department but who reported a transient loss of consciousness were included. Patients were divided into two groups, patients aged > or = 60 years (n = 21) and patients aged < 60 years (n = 31). In all patients a head CT scan was performed. Nine abnormal CT scans were found in the group of patients aged > or = 60 years (three head fractures, three brain contusion, two subarachnoid haemorrhages, and one subdural haematoma) and one abnormal CT scan in the group of patients aged < 60 years (cranial fracture). This difference was statistically significant (p < 0.001). In conclusion, an urgent head CT scan should be performed in patients aged over 60 years with mild head trauma and loss of consciousness. In younger patients this scan should be performed when the patient presents with headache and vomiting.

[Indications for brain scan in patients presenting benign cranial injury].

Validate the clinical criteria, which, when absent, would make it safe to bypass CT scan examination in mild cranial injuries. and methods. Prospective study including 285 patients with mild cranial injury with a Glasgow score of 15, a normal clinical examination but transitory loss of consciousness or suspected transitory loss of consciousness. The following clinical parameters were systematically reviewed: history of stroke; post-injury headache; post-injury vomiting; alcohol, medication, or drug intoxication; clinical signs of cervico-cranio-facial injury; post-injury convulsions; or coagulation impairment. Systematic CT exploration looked for cranial, encephalic, and facial lesions and individualized the lesions requiring neurosurgical or maxillofacial treatment. Of the patients studied, 7% presented a cranioencephalic lesion and 7% a facial bone lesion. Neurosurgical intervention was necessary in 0.4% of the patients and maxillofacial surgery in 2.5%. Patients with a positive CT all had at least one clinical risk factor and patients with cranioencephalic lesions had at least two risk factors present. Had patients with no risk factors not been scanned, 15% of the patients would not have had the CT procedure. Selecting CT indications in cases of mild cranial injury with loss of consciousness using a simple and validated evaluation can save 15% of CT procedures without missing any cranial, encephalic, or facial lesions.

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients.

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.

Evaluation of mild head injury in a pediatric population.

Approximately 5 million children present to emergency departments, seeking care for head injuries, each year, and 80% of these children are classified as cases of mild head injury. Due to the huge number of patients and low frequency of intracranial lesions in this group, obtaining a computed tomography scan for each and every patient is a significant economic problem. This study was conducted to identify the clinical parameters and the radiographic findings that may be associated with intracranial lesions in children with mild head injury. 421 patients, with a Glasgow Coma Scale score of 15 and without any focal neurological deficit, were studied. Intracranial lesion was noted in 37 cases (8.8%). Sensitivity of a plain radiogram was 43.2%, and specificity was 93%. An intracranial pathology was demonstrated in 28.9% of the patients with a linear skull fracture. The only clinical parameters associated with an increase in the frequency of detection of intracranial lesions were posttraumatic seizures and loss of consciousness. Age, sex, headache, vomiting and scalp lacerations were not associated with a higher frequency. Even when patients with a history of loss of consciousness or posttraumatic seizure were subtracted from the study group, intracranial lesions were noted in 4.1% of the cases, and in 1.8% neurosurgical intervention was required. Computed tomography is the gold standard in the evaluation of pediatric patients with mild head trauma, and every child who has experienced a head injury should undergo a cranial computed tomography evaluation, even if he or she appears in perfect health.

Canadian CT head rule

Under the CCTHR, patients with minor head injuries should only receive CT scans if one or more of the following criteria are met: Glasgow Coma Scale score lower than 15 at 2 hours after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Two or more episodes of vomiting Age 65 or older Amnesia before impact of 30 or more minutes Dangerous mechanism (this is defined by Stiell et al. (2005) as "a pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from an elevation of 3 or more feet or 5 stairs.") The first five criteria are considered "high-risk", whereas criteria 6 and 7 are considered "medium-risk". References External links Canadian CT head rule on Radiopaedia Medical scales Tomography

Neurology_Adams

With the current focus on the cost-effective use of ancillary studies, criteria that justify obtaining a cranial CT following minor forms of head trauma have been developed as discussed in the next paragraph. We have generally advised a CT in cases of head injury that was associated with loss of consciousness (more than 1 min), severe and persisting headache, nausea and vomiting, a confusional state, and any new, objective neurologic signs, but these are admittedly arbitrary criteria. The CT scan may be particularly important in elderly patients with minor head trauma, in whom the presence of an intracranial lesion (mainly subdural hematoma) may not be predicted by clinical signs and, of course, imaging may be advisable if the patient is taking anticoagulants or antiplatelet agents of any type beyond small doses of aspirin. In children, it may be advisable to perform the scans more liberally. This is underscored by the results of a study of 215 children with minor head trauma

Concussion

Diagnosis Head trauma recipients are initially assessed to exclude a more severe emergency such as an intracranial hemorrhage. This includes the "ABCs" (airway, breathing, circulation) and stabilization of the cervical spine which is assumed to be injured in any athlete who is found to be unconscious after head or neck injury. Indications that screening for more serious injury is needed include worsening of symptoms such as headaches, persistent vomiting, increasing disorientation or a deteriorating level of consciousness, seizures, and unequal pupil size. Those with such symptoms, or those who are at higher risk of a more serious brain injury, may undergo brain imaging to detect lesions and are frequently observed for 24–48 hours. A brain CT or brain MRI should be avoided unless there are progressive neurological symptoms, focal neurological findings or concern of skull fracture on exam.

Risk factors for positive brain CT scan in children with traumatic brain injury and GCS = 15: A retrospective study.

It is controversial whether it is necessary to carry out head computed tomography (CT) examination for children who had a traumatic brain injury (TBI) but are conscious (Glasgow Coma Scale (GCS) = 15). The present study explored the risk/predictive factors of positive CT results in children with mild closed head injury and GCS = 15.This was a retrospective study of children (0-18 years of age) with TBI and GCS = 15 and treated at the First People's Hospital of Wenling between 06/2013 and 06/2018. The outcome was a positive head plain CT result. Univariable and multivariable logistic regression analyses were carried out to determine the factors independently associated with positive CT results.A total of 279 children were included. The majority of the injured were boys (180/279, 64.5%). The top three causes of injury were traffic accidents (100/279, 35.8%), falling from height (92/279, 33.0%), and tumble (72/279, 25.8%). The top three clinical symptoms were headache (201/279, 72.0%), scalp hematoma (133/279, 47.7%), and nausea with or without vomiting (105/279, 37.6%). The multivariable analysis showed that scalp hematoma (OR = 3.040, 95%CI: 1.791-5.159, P < .0001), ear and nostril bleeding or periorbital soft tissue contusion (OR = 2.234, 95%CI: 1.087-4.590, P = .029), and nausea with or without vomiting (OR = 2.186, 95%CI: 1.255-3.810, P = .006) were independently associated with positive results of head CT.For children with TBI and GCS = 15, the factors independently associated with positive CT results are scalp hematoma, ear and nostril bleeding or periorbital soft tissue contusion, and nausea with or without vomiting.

InternalMed_Harrison

Persistent severe headache and repeated vomiting in the context of normal alertness and no focal neurologic signs is usually benign, but CT should be obtained and a longer period of observation is appropriate. The decision to perform imaging tests also depends on clinical signs that indicate that the impact was severe (e.g., persistent confusion, periorbital or mastoid hematoma, repeated vomiting, palpable skull fracture), on the seriousness of other bodily injuries, and on the degree of surveillance that can be anticipated after discharge. Two studies have indicated that older age, two or more episodes of vomiting, >30 min of retrograde or persistent anterograde amnesia, seizure, and concurrent drug or alcohol intoxication are sensitive (but not specific) indicators of intracranial hemorrhage that justify CT scanning. It may be appropriate to be more liberal in obtaining CT scans in children because a small number, even without loss of consciousness, will have intracranial traumatic

Which mild head injured patients should have follow-up after discharge from an accident and emergency ward? A study in a university hospital setting in Kelantan, Malaysia.

Mild head injury (MHI) is a common presentation to many hospitals in both rural and urban settings in Southeast Asia, but it is not well studied. We studied 330 patients that presented to Hospital Universiti Sains Malaysia Emergency Department with possible MHI, with the intentions to identify prognostic factors that may improve the diagnosis of MHI in the emergency setting as well as to determine which patients would need follow-up. Patients' one-year outcomes were classified as discharged well (DW) for patients without post-traumatic signs and symptoms and discharged with long term follow-up (DFU) for patients with such signs and symptoms. Four patients died and 82 were DFU. An abnormal skull X ray was associated with mode of accident and type of transportation, older age, presence of vomiting, confusion, bleeding from ear, nose or throat, abnormal pupil size on the right side associated with orbital trauma, unequal pupillary reflexes, absence of loss of consciousness (LOC), a lower Glasgow Coma Scale (GCS) score, multiple clinical presentations, and DFU. An abnormal CT scan was associated with older age, multiple clinical presentation, skull X-ray findings, and DFU. A similar analysis on outcomes revealed that mode of accident, older age, vomiting, confusion, headache, bleeding from ear, nose and throat, neurological deficits, absence of LOC, pupil size, multiple presentation, abnormal skull X ray, CT scan of the brain, and a GCS of 13 was associated with DFU. In conclusion, all patients involved in motor vehicle accidents (MVAs), especially motorcycles, aged over 30 years of age, with multiple clinical presentations, including a lower GCS, and with abnormal radiological findings should have a longer follow-up due to persistent post-traumatic symptomatology.

Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department.

Older age is a risk factor for intracranial injury after head trauma, and computed tomography (CT) is generally recommended. We aimed to develop a clinical prediction rule for risk stratification to avoid CT head imaging in older adult patients with minor head injury, named Computed Tomography of the Head for the patients at Advanced age (CTHEAD). This was a single-center observational study in Japan that used retrospective chart review data to service a prediction rule that was prospectively validated. Patients aged ≥ 65 years who presented to our emergency department with a chief complaint of head trauma and a Glasgow Coma Scale (GCS) of ≥13 were eligible. Patients were excluded if they had GCS score < 13, anticoagulant therapy, focal neurologic symptoms, posttraumatic seizures, penetrating injury, evident depressed fracture, unknown mechanism, or CT not undertaken. The primary outcome was acute traumatic lesion on head CT. We screened 1,494 patients; 538 were included in the derivation cohort, and 580, in the validation cohort. Multivariable analysis of the derivation group found that high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, and anterograde amnesia were significantly associated with traumatic head findings on CT. A clinical prediction rule was developed from these four risk factors. The negative predictive value (NPV) of the absence of the four components was 95.1% (95% confidence interval [CI] = 92.9% to 96.7%), and the positive predictive value (PPV) of one or more risk factors was 20.6% (95% CI = 17.3% to 24.4%). The rule was validated prospectively with an NPV of zero risk factors of 94.5% (95% CI = 92.4% to 96.1%) and a PPV of one or more risk factors of 15.9% (95% CI = 13.0% to 19.3%). Fifty-three (9.1%) patients in the validation cohort experienced the primary outcome. The results suggest that older adult patients with minor head injury may forgo head CT if they do not have high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, or anterograde amnesia. External validation of this rule is needed.

Computed tomography of the head

Even in emergency situations, when a head injury is minor as determined by a physician's evaluation and based on established guidelines, CT of the head should be avoided for adults and delayed pending clinical observation in the emergency department for children. Many people visit emergency departments for minor head injuries. CT scans of the head can confirm a diagnosis of skull fracture or brain bleeding, but even in the emergency department, such things are uncommon and not minor injuries, so CT of the head is usually not necessary. Clinical trials have shown the efficacy and safety of using CT of the head in emergency settings only when indicated, which would be at the indication of evidence-based guidelines following the physical examination and a review of the person's history.

[Head trauma in a general surgery department: observations, diagnostic and therapeutic indications].

The authors reviewed the records of 927 patients admitted to Surgical Clinic University of L'Aquila from November 1986 to July 1990 with head trauma. The 5.6% (52 patients) had skull fractures. 23 (2.4%) patients sustained significant intracranial sequelae from their injuries, but only 4 (17.3%) of these also sustained fractures, 17 did not. Of the four fractures 1 were simple, 2 was depressed and 1 was basilar. The patients (17) without a skull fracture and positive CT were transferred to a neurosurgical department, where 12 underwent operation. The patients (4) with a skull fracture and positive CT and 2 patients with a depressed skull fracture and negative CT were transferred to a neurosurgical department where 5 (except 1 patient with simple fracture) underwent operation. The severity of coma was evaluated according to Glasgow Coma Scale (G.C.S.). The 2.4% of patients had the Glasgow Coma Scale = or less than 7. The CT or MNR are indicate in the presence of neurologic abnormalities. Overall mortality rate was about 0.53%. In the severe head trauma (G.C.S. = or less than 7) was of 17,3. the skull radiography is not indicated of routine and are performed for the evaluation of depressed fractures, of fracture of the cranial base and of cervical vertebrae: the MNR was found to be superior to CT and to be very effective in the detection of traumatic head lesions: the Glasgow Coma Scale is important for monitoring, stratification and prognostic evaluation of patients.


Direct response question. This is syphilis (both by antecendent and serology) in the secondary stage, so treatment is with Benzathine Penicillin 2.4 MU in a single dose.

A 34-year-old man consults for fever and malaise. The medical history includes a history of homosexual relations for the last 4 months with a new partner. 2 months before the current consultation he had a painless ulcerative lesion on the glans penis with bilateral inguinal lymphadenopathy, all self-limited. Serological studies were requested with the following results: HIV negative, RPR 1/320, HAART 1/128. What treatment would you indicate for this patient?

Intravenous penicillin G, 24 MU every day for 14 days.

Benzathine penicillin 2.4 MU intramuscular, 3 doses in three consecutive weeks.

Ceftriaxone 2 grams intramuscular in a single dose.

Benzathine penicillin 2.4 MU intramuscularly in a single dose.

Lues maligna praecox: an important consideration in HIV-positive patients with ulceronodular skin lesions.

Syphilis is commonly known as "the great imitator" owing to its varied clinical manifestations. Secondary syphilis has a variety of presentations, with the most common manifesting as a diffuse papulosquamous eruption on the palms and soles. Lues maligna praecox is a rare form of secondary syphilis, with severe constitutional symptoms, seen primarily in HIV-positive individuals. We report an atypical case of suspected lues maligna in a 45-year-old male. The patient was HIV-positive with a CD4 count of 441. He presented to our clinic with large painful gummatous ulcers in the groin and lower back. He also reported daily fevers, night sweats, and weight loss consistent with secondary syphilis. Prior to this episode the patient had a history of acute active syphilis (RPR 1:128) in 2012 treated at that time with a single dose of 2.4 million units intramuscular benzathine penicillin; he had no reported exposures since that time. The patient was treated with three weekly doses of benzathine penicillin, 2.4 million units, given intramuscularly. This case demonstrates the importance of recognizing the varied clinical presentation of secondary syphilis and keeping lues maligna in consideration for ulceronodular skin lesions in patients who are HIV-positive.

Single Dose Versus 3 Doses of Intramuscular Benzathine Penicillin for Early Syphilis in HIV: A Randomized Clinical Trial.

Patients coinfected with syphilis and human immunodeficiency virus (HIV) may have a slower decrease in rapid plasma reagin (RPR) titers. Currently a single dose of 2.4 million units of intramuscular benzathine penicillin G (BPG) is recommended for the treatment of early syphilis. Some observational studies have suggested that this regimen may lead to high failure rates in coinfected patients. We conducted an open-label randomized clinical trial to compare the efficacy of single-dose and 3-dose regimens of BPG for the treatment of early syphilis in HIV-infected individuals. RPR titers were monitored every 3 months. Treatment success was defined as a decrease in RPR titers of ≥2 dilutions (4-fold) during a 12-month follow-up period. Sixty-four patients were included. In the intention-to-treat analysis, treatment success rates were 80% (28 of 35 subjects) and 93% (27 of 29 subjects) in the single-dose and 3-dose regimens, respectively (absolute difference, 13% [95% confidence interval {CI}, -5% to 30%; P = .17). In the per-protocol analysis, success rates were 93% (27 of 29) and 100% in the single-dose and 3-dose regimens, respectively (absolute difference, 7% [95% CI, -7% to 22%]; P = .49). CD4 T-cell count, RPR titer and syphilis stage did not affect treatment results. When compared with a single dose of BPG, a 3-dose regimen did not improve syphilis serological outcomes. Our results support the Centers for Disease Control and Prevention recommendation of a single dose of BPG in HIV-infected patients with early syphilis. NCT02611765.

Single-dose azithromycin versus penicillin G benzathine for the treatment of early syphilis.

Pilot studies suggest that a single, 2-g oral dose of azithromycin may be an alternative to a 2.4-MU intramuscular dose of penicillin G benzathine in the prevention and treatment of syphilis. We evaluated the efficacy of treatment with azithromycin in a developing country. A total of 328 subjects, 25 with primary and 303 with high-titer (a titer of at least 1:8 on a rapid plasmin reagin [RPR] test) latent syphilis, were recruited through screening of high-risk populations in Mbeya, Tanzania, and randomly assigned to receive 2 g of azithromycin orally (163 subjects) or 2.4 million units of penicillin G benzathine intramuscularly (165 subjects). The primary outcome was treatment efficacy, with cure defined serologically (a decline in the RPR titer of at least two dilutions by nine months after treatment) and, in primary syphilis, by epithelialization of ulcers within one or two weeks. The average age of participants was 27.0 years, 235 (71.6 percent) were female, and 171 (52.1 percent) were seropositive for human immunodeficiency virus. Cure rates were 97.7 percent (95 percent confidence interval, 94.0 to 99.4) in the azithromycin group and 95.0 percent (95 percent confidence interval, 90.6 to 97.8) in the penicillin G benzathine group (95 percent confidence interval for the difference, -1.7 to 7.1 percent), achieving prespecified criteria for equivalence. Cure rates were also similar three and six months after treatment in the two groups and in all subgroups. Cure rates at three months were 59.4 percent (95 percent confidence interval, 51.8 to 67.1) in the azithromycin group and 59.5 percent (95 percent confidence interval, 51.8 to 67.3) in the penicillin G benzathine group and at six months were 85.5 percent (95 percent confidence interval, 79.4 to 90.6) and 81.5 percent (95 percent confidence interval, 74.8 to 87.4), respectively. Single-dose oral azithromycin is effective in treating syphilis and may be particularly useful in developing countries in which the use of penicillin G benzathine injections is problematic. However, recent reports of azithromycin-resistant Treponema pallidum in the United States indicate the importance of continued monitoring for resistance.

InternalMed_Harrison

Stage of Syphilis Patients without Penicillin Allergy Patients with Confirmed Penicillin Allergyb Primary, secondary, or early latent Late latent (or latent of uncertain duration), cardiovascular, or benign tertiary Syphilis in pregnancy CSF normal or not examined: Penicillin G benzathine (single dose of 2.4 mU IM) CSF abnormal: Treat as neurosyphilis CSF normal or not examined: Penicillin G benzathine (2.4 mU IM weekly for 3 weeks) CSF abnormal: Treat as neurosyphilis Aqueous crystalline penicillin G (18–24 mU/d IV, given as 3–4 mU q4h or continuous infusion) for 10–14 days Aqueous procaine penicillin G (2.4 mU/d IM) plus oral probenecid (500 mg qid), both for 10–14 days According to stage CSF normal or not examined: Tetracycline HCl (500 mg PO qid) or doxycycline (100 mg PO bid) for 2 weeks CSF abnormal: Treat as neurosyphilis CSF normal and patient not infected with HIV: Tetracycline HCl (500 mg PO qid) or doxycycline (100 mg PO bid) for 4 weeks

Syphilis -- Treatment / Management

Treatment depends on the disease stage. Primary, secondary, or early latent syphilis is treated with a single dose of intramuscular (IM) benzathine penicillin G 2.4 million units. Neurosyphilis is treated with IV penicillin G aqueous 18-24 million units daily for 14 days. An alternative regimen would be procaine penicillin G 2.4 million units IM once daily AND Probenecid 500 mg orally 4 times/day for 10–14 days. Tertiary and latent syphilis and HIV-infected patients should be treated with weekly benzathine penicillin G 2.4 million units IM for three weeks.

A randomized, comparative pilot study of azithromycin versus benzathine penicillin G for treatment of early syphilis.

Penicillin is the only medication currently recommended for treatment of early syphilis in non-penicillin-allergic patients. Preliminary data suggest that azithromycin may be effective for syphilis therapy. This was a randomized, comparative pilot study of intramuscular injections of benzathine penicillin G and two oral azithromycin regimens for treatment of syphilis. We randomly assigned patients with early syphilis to treatment with either intramuscular injections of 2.4 million units of benzathine penicillin G or azithromycin administered orally, either as a single 2.0-g dose or as two 2.0-g doses given 1 week apart. Serological response to therapy was evaluated at 3, 6, 9, and 12 months following therapy. Participants whose rapid plasma reagin (RPR) test became nonreactive or whose RPR titer decreased > or =2 dilutions were classified as responding to therapy. When serological tests did not show a response to therapy, the treatment was classified as a failure if RPR titers increased > or =2 dilutions. Nonresponders were those whose serologic titers remained within +/-1 dilution of the initial RPR titer. Cumulative response rates were as follows: benzathine penicillin G, 86% (12 of 14); azithromycin, 2.0-g single dose, 94% (16 of 17); and azithromycin, two 2.0-g doses given 1 week apart, 83% (24 of 29). Therapy failed for one patient treated with benzathine penicillin and one patient treated with the two-dose azithromycin regimen, whereas in six patients the clinical manifestations of infection resolved but there was no serological response. Oral therapy with 2.0 g of azithromycin as a single dose or as two doses 1 week apart is a promising alternative to therapy with benzathine penicillin G for syphilis and should be studied further.

A Single Dose Oral Azithromycin versus Intramuscular Benzathine Penicillin for the Treatment of Yaws-A Randomized Non Inferiority Trial in Ghana.

Yaws is a treponemal infection that was almost eradicated fifty years ago; however, the disease has re-emerged in a number of countries including Ghana. A single-dose of intramuscular benzathine penicillin has been the mainstay of treatment for yaws. However, intramuscular injections are painful and pose safety and logistical constraints in the poor areas where yaws occurs. A single center randomized control trial (RCT) carried out in Papua New Guinea in 2012 demonstrated the efficacy of a single-dose of oral azithromycin for the treatment of yaws. In this study, we also compared the efficacy of a single oral dose of azithromycin as an alternative to intramuscular benzathine penicillin for the treatment of the disease in another geographic setting. We conducted an open-label, randomized non-inferiority trial in three neighboring yaws-endemic districts in Southern Ghana. Children aged 1-15 years with yaws lesions were assigned to receive either 30mg/kg of oral azithromycin or 50,000 units/kg of intramuscular benzathine penicillin. The primary end point was clinical cure rate, defined as a complete or partial resolution of lesions 3 weeks after treatment. The secondary endpoint was serological cure, defined as at least a 4-fold decline in baseline RPR titre 6 months after treatment. Non- inferiority of azithromycin treatment was determined if the upper bound limit of a 2 sided 95% CI was less than 10%. The mean age of participants was 9.5 years (S.D.3.1, range: 1-15 years), 247(70%) were males. The clinical cure rates were 98.2% (95% CI: 96.2-100) in the azithromycin group and 96.9% (95% CI: 94.1-99.6) in the benzathine penicillin group. The serological cure rates at 6 months were 57.4% (95% CI: 49.9-64.9) in the azithromycin group and 49.1% (95% CI: 41.2-56.9) in the benzathine penicillin group, thus achieving the specified criteria for non-inferiority. A single oral dose of azithromycin, at a dosage of 30mg/kg, was non-inferior to a single dose of intramuscular benzathine penicillin for the treatment of early yaws among Ghanaian patients, and provides additional support for the WHO policy for use of oral azithromycin for the eradication of yaws in resource-poor settings. Pan African Clinical Trials Registry PACTR2013030005181 http://www.pactr.org/.

Comparisons of Serologic Responses of Early Syphilis to Treatment with a Single-Dose Benzathine Penicillin G Between HIV-Positive and HIV-Negative Patients.

Poorer serologic responses of early syphilis to treatment have been inconsistently reported in HIV-positive patients compared with HIV-negative patients, but the interpretation of previous studies is limited by discrepant study designs. The present study aimed to evaluate the effect of HIV infection on the treatment response to a single dose of benzathine penicillin G (BPG) for early syphilis. From January 2015 to March 2020, adult patients with early syphilis who received a single dose of BPG were enrolled and rapid plasma reagin (RPR) titers were periodically determined. The primary outcome was serologic response, defined as at least a fourfold decline of RPR titer at 12 months of BPG treatment compared with that at baseline, which was examined in the intention-to-treat (ITT) and per-protocol analyses. Treatment failure included lack of at least a fourfold decline in RPR titers and at least a fourfold increase in RPR titers. We prospectively enrolled 184 HIV-positive and 68 HIV-negative participants with early syphilis, who were all men who have sex with men, with a higher proportion of previous syphilis (70.1%) and early latent syphilis (64.1%) among HIV-positive participants. In the ITT with last-observation-carried-forward analysis, HIV-positive participants had a significantly lower serologic response rate at 12 months of treatment than HIV-negative participants (73.4% vs. 91.2%). Of HIV-positive participants, 12.5% failed to achieve at least fourfold decline in RPR titers and 14.1% had at least a fourfold increase in RPR titers. The factors associated with 12-month serologic response were HIV infection (adjusted odds ratio [AOR] 0.33; 95% confidence interval [CI] 0.13-0.81) and RPR titer (per 1-log<sub2</sub increase, AOR 1.36; 95% CI 1.23-1.51). HIV-positive patients with early syphilis had poorer serologic responses to BPG treatment than HIV-negative patients during a 12-month follow-up period.

A Case of Early Neurosyphilis.

Neurosyphilis is an infection of the central nervous system by Treponema pallidum, which can occur after the initial syphilis infection. Although commonly associated with late stage disease, patients with early neurosyphilis may present with acute syphilitic meningitis, meningovascular syphilis, or uveitis. A 28 year old man with a past medical history of HIV (CD4 364);, and recent diagnosis of uveitis presented to the Emergency Department with a positive RPR result. His visual acuity had been gradually declining over the past few months. He denied painless or painful ulcerating lesions on his penis, or scrotum, difficulty concentrating, dermatitis on the soles/palms, or difficulty with proprioception. Physical exam was notable for atrophic hyperpigmented polycyclic, annular plaques and patches along the hairline as well as several areas of confluent hyperpigmented polycyclic plaques and nodules on the patient's face, back, left arm, and right posterior leg. Fundoscopic exam revealed bilateral posterior uveitis and chorioretinitis. Evaluation of cerebrospinal fluid revealed a lymphocytic pleocytosis with a positive VDRL and FTA-ABS. Aqueous crystalline penicillin G was initiated for treatment of early neurosyphilis. Within six hours of beginning the infusion, the patient had a documented temperature of 101.8°F, heart rate of 128 beats per minute, blood pressure 142/84, with generalized malaise and headache. Fever and tachycardia resolved over the next 12 hours, with weakness and headache resolving within 1-2 days. His symptom complex was consistent with the Jarisch-Herxheimer reaction. Histopathology of skin biopsy of the back showed perivascular inflammation and rare spirochetes, consistent with secondary syphilis. The patient completed 14 days of aqueous crystalline penicillin G and was discharged after receiving the first of three benzathine penicillin injections. The initial manifestations of syphilis in this patient were posterior uveitis and pruritic skin plaques. His diagnosis should be appropriately classified as secondary syphilis with concomitant symptomatic early neurosyphilis, requiring 14 days of aqueous crystalline penicillin G. This type of presentation is not specific to immunocompromised populations and must be considered even in the general population. Making the diagnosis of early neurosyphilis, regardless of stage, is critical, as it necessitates a longer duration of treatment. Furthermore, clinicians should be reminded of the profound immunologic reaction, Jarisch-Herxheimer, which may occur when treating any treponemal disease.

One dose versus three weekly doses of benzathine penicillin G for patients co-infected with HIV and early syphilis: a multicenter, prospective observational study.

One dose of benzathine penicillin G (BPG) has been recommended for HIV-infected patients with early syphilis (primary, secondary, and early latent syphilis) in the sexually transmitted diseases treatment guidelines, but clinical data to support such a recommendation are limited. We prospectively observed the serological response to 1 or 3 weekly doses of BPG in HIV-infected adults who sought treatment of early syphilis at 8 hospitals around Taiwan. Rapid plasma reagin (RPR) titers were followed every 3-6 months after treatment. The serological response was defined as a 4-fold or greater decline in RPR titers at 12 months of treatment. The missing values were treated by following the last-observed-carried-forward principle. We hypothesized that 1 dose was non-inferior to 3 weekly doses of BPG with the non-inferiority margin for the difference of serological response set to 10%. Between 2007 and 2012, 573 patients completed at least 12 months of follow-up: 295 (51.5%) receiving 1 dose of BPG (1-dose group) and 278 (48.5%) 3 doses (3-dose group). Overall, 198 patients (67.1%; 95% confidence interval [CI], 61.4-72.5%) in the 1-dose group achieved serological response at 12 months, as did 208 patients (74.8%; 95% CI, 69.3-79.8%) in the 3-dose group (one-sided 95% CI of the difference, 15.1%). In the multivariate analysis, secondary syphilis (adjusted odds ratio [AOR], 1.90; 95% CI 1.17-3.09), RPR titer ≥32 (AOR, 1.93; 95% CI, 1.38-2.69), and 3 doses of BPG (AOR, 1.68; 95% CI, 1.20-2.36) were independently associated with a serological response. The time to the first episode of treatment failure was 1184 (standard deviation [SD], 70.5) and 1436 (SD, 80.0) days for 1- and 3-dose group, respectively. Single-dose BPG resulted in a higher serological failure rate and shorter time to treatment failure than 3 weekly doses of BPG in the treatment of early syphilis in HIV-infected patients.

A 30-Year-Old Man with HIV, Fever, and a Rash.

Patients who present with papular rashes have a wide differential diagnosis particularly in the setting of immune compromise. A 30-year-old male diagnosed with HIV since 2009, never on antiretroviral therapy, with a nadir CD4 count of 333 cells/mm<sup3</sup and a current viral load of 44,300 copies/mL, presented with a diffuse monomorphic papular eruption that began on his trunk and extremities and subsequently spread to the penis and scrotum, sparing the distal acral sites. A thorough infectious workup revealed a positive rapid plasma reagin (RPR) and varicella IgM and IgG antibodies. Interestingly, the patient had been diagnosed and treated for syphilis in the past with a recent downtrending RPR drawn prior to hospitalization. Repeat RPR was elevated and a preliminary histopathology report demonstrated folliculocentric inflammation with lymphocytes, plasma cells, and polymorphonuclear leukocyte predominance supported the diagnosis of syphilis. After receiving intramuscular penicillin G benzathine, he developed intermittent fevers and new papules. Intravenous (IV) acyclovir was initiated for presumed disseminated varicella given his positive varicella-zoster virus IgM and IgG. However, final pathology results revealed a large spirochete burden. The fevers and rash progression were attributed to the development of a Jarisch-Herxheimer reaction. IV acyclovir was discontinued and he completed a course of intramuscular penicillin G benzathine. He was also given a course of doxycycline for rectal chlamydia which was diagnosed during hospitalization.

[Single dose treatment of primary syphilis with Benzathine penicillin (author's transl)].

Out of 40 male patients with primary syphilis diagnosed microscopically by dark field preparations and by serological tests 20 patients were treated with a single intramuscular injection of 4.8 millions I. U. Benzathine penicillin and 20 patients with a daily intramuscular injection of 1 million I. U. Clemizol penicillin over a period of 21 days. In all patients success of treatment was verified by complete remission of the clinical symptoms and by serological tests over a period of 2 years. Single dose treatment with Benzathine penicillin represents a simple and reliable method of treatment of primary syphilis.

Rheumatic fever prophylaxis in South Africa--is bicillin 1,2 million units every 4 weeks appropriate?

Rheumatic fever is a major health problem in South Africa. Although intramuscular benzathine penicillin (bicillin) 1.2 million units (MU) every 4 weeks is widely used for secondary prophylaxis, studies in other countries have shown a recurrence rate of 3-8% over 5-6 years in patients on this regimen. It has been recommended that serum penicillin concentrations should be maintained above 0.02 mg/ml to prevent such recurrences. The World Health Organisation (WHO) and the American Heart Association have recommended since 1988 that patients in high-risk areas for the development of rheumatic fever should receive benzathine penicillin 1.2 MU every 3 weeks rather than every 4. The aims of this study were, firstly, to determine the prevalence of serum penicillin concentrations below 0.02 micrograms/ml in rheumatic fever patients on benzathine penicillin 1.2 MU 4-weekly and, secondly, to study the effect of increasing the dose of 1.8 MU 4-weekly in patients with subtherapeutic concentrations. Forty-five of 51 rheumatic fever patients (88%) in this study on benzathine penicillin 1.2 MU 4-weekly had low serum penicillin concentrations (< 0.02 micrograms/ml) at the end of the 4th week after the injection. Penicillin was detected in the urine of 30 of the 45 patients (67%) with low concentrations, suggesting that such patients have tissue-bound penicillin which might be important in preventing rheumatic fever. The 15 patients (33%) with subtherapeutic serum penicillin concentrations and no detectable penicillin in the urine could be at very high risk for recurrent attacks of rheumatic fever. Fourteen of 29 patients (48%) given the higher dose of benzathine penicillin (1.8 MU 4-weekly) had subtherapeutic serum penicillin concentrations at the end of the 4th week after the injection, but in all 29 penicillin was detected in the urine. Review of our present policy of secondary prophylaxis for rheumatic fever is necessary. Concentrated preparations of benzathine penicillin (600,000 U/ml) are not available in South Africa; administration of a higher dose (1.8 MU) 4-weekly would therefore require a double injection, which could affect compliance adversely. We recommend that rheumatic fever patients in our area should receive benzathine penicillin 1.2 MU 3-weekly as recommended by the WHO until strategies for secondary prophylaxis have been evaluated further.

InternalMed_Harrison

Syphilitic meningitis is treated with aqueous penicillin G in a dose of 3–4 million units intravenously every 4 h for 10–14 days. An alternative regimen is 2.4 million units of procaine penicillin G intramuscularly daily with 500 mg of oral probenecid four times daily for 10–14 days. Either regimen is followed with 2.4 million units of benzathine penicillin G intramuscularly once a week for 3 weeks. The standard criterion for treatment success is reexamination of the CSF. The CSF should be reexamined at 6-month intervals for 2 years. The cell count is expected to normalize within 12 months, and the VDRL titer to decrease by two dilutions or revert to nonreactive within 2 years of completion of therapy. Failure of the CSF pleocytosis to resolve or an increase in the CSF VDRL titer by two or more dilutions requires retreatment.

A single dose of benzathine penicillin G is as effective as multiple doses of benzathine penicillin G for the treatment of HIV-infected persons with early syphilis.

Treatment guidelines recommend the use of a single dose of benzathine penicillin G (BPG) for treating early syphilis in human immunodeficiency virus (HIV)-infected persons. However, data supporting this recommendation are limited. We examined the efficacy of single-dose BPG in the US Military HIV Natural History Study. Subjects were included if they met serologic criteria for syphilis (ie, a positive nontreponemal test [NTr] confirmed by treponemal testing). Response to treatment was assessed at 13 months and was defined by a ≥4-fold decline in NTr titer. Multivariate Cox proportional hazard regression models were utilized to examine factors associated with treatment response. Three hundred fifty subjects (99% male) contributed 478 cases. Three hundred ninety-three cases were treated exclusively with BPG (141 with 1 dose of BPG). Treatment response was the same among those receiving 1 or >1 dose of BPG (92%). In a multivariate analysis, older age (hazard ratio [HR], 0.82 per 10-year increase; 95% confidence interval [CI], .73-.93) was associated with delayed response to treatment. Higher pretreatment titers (reference NTr titer <1:64; HR, 1.94 [95% CI, 1.58-2.39]) and CD4 counts (HR, 1.07 for every 100-cell increase [95% CI, 1.01-1.12]) were associated with a faster response to treatment. Response was not affected by the number of BPG doses received (reference, 1 dose of BPG; HR, 1.11 [95% CI, .89-1.4]). In this cohort, additional BPG doses did not affect treatment response. Our data support the current recommendations for the use of a single dose of BPG to treat HIV-infected persons with early syphilis.

Analysis of serological treatment response to doxycycline versus benzathine penicillin in syphilis infections, a retrospective single-center study.

Doxycilicine is the second-line treatment of choice for infectious syphilis when treatment with penicillin G is not feasible. To date, difficulties in the penicillin supply chain make it necessary to evaluate and resort to antibiotic therapies which are currently considered a second-line choice. Moreover, systematic studies comparing the two treatments in affected patients are still few, and many do not consider late and indeterminate latent infections. The objective of this study was to assess the differences in the serological response of the treatment of syphilis infections with benzathine penicillin compared with doxycycline. We built an in-house database with all patients diagnosed with syphilis infection from January 2010 to January 2020 in the STD Centre of the S.Orsola-Malpighi Polyclinic of the University of Bologna, located in the North-east of Italy. We recorded all the principal independent (demographic, social status, reinfection rare, HIV infections, comorbidities, sexual behaviors, and initial TPHA values) and dependent variables (RPR values). We then extrapolated all patients treated with doxycycline (100 mg of doxycycline twice daily for 14 days for infections diagnosed within the first year and a 28 days course for infections older than 1 year or undetermined) and matched in 1:1 ratio numbers with a homogeneous group of patients treated with penicillin G (2.4 million units in a single dose intramuscularly for infections diagnosed within the first year and a cycle consisting in of 2.4 million units administered in a single dose per week for 3 weeks for infections older than 1 year or undetermined) We then analyzed the serological trends and outcomes in the primary, secondary and early latent groups versus late latent and undetermined infections. We retrieved 41 patients for each group with homogeneous initial characteristics. At the end of the 24-month observation period, a slight difference in a valid RPR reduction rate emerged, with a greater success rate emerged in patients receiving penicillin than those with doxycycline (26 vs. 22, p 0.615). Indeed, patients with latent or indeterminate syphilis treated with doxycycline appear to have a higher rate of serofast than those treated with penicillin. Linear regression analysis showed no strong correlation between the analyzed independent variables and the observed outcomes. Doxycycline had a slightly lower, though not statistically different, success rate when compared with penicillin in treating primary syphilis, but appeared to have a reduced success rate in attaining resolution in late and undetermined syphilis infection.

Treatment of late syphilis with 2.4 million units benzathine penicillin G (BPG): tolerance of single versus divided doses.

Although there is no data in the literature, some textbooks recommend fractioning the injection of benzathine penicillin G (BPG) for alleviating the pain. In a monocentric study done in 50 consecutive patients with late syphilis. Patients were assigned to receive 1 dose of 2.4 million units BPG intramuscularly the first week and 2 doses of 1.2 million units BPG in each buttock the second week. In the third week, patients were asked to choose between the 2 options. It was demonstrated that the 2 techniques were equally well tolerated and equally preferred by patients.

Benzathine Penicillin -- Administration -- Adult

Pharyngitis/tonsillitis, group A streptococci (1.2 million units IM x 1) Upper respiratory infection, group A streptococci that are mild to moderate and are susceptible to low, prolonged concentrations of benzathine penicillin (1.2 million units intramuscularly [IM] x 1) Secondary prevention of glomerulonephritis (prophylaxis for patients with a history of acute glomerulonephritis) (1.2 million units IM every four weeks or 600,000 units IM twice monthly) Secondary prevention (prophylaxis) of rheumatic fever (1.2 million units IM every 3 to 4 weeks or 600,000 units IM twice monthly) Syphilis: Primary, secondary, or latent less than one year (2.4 million units IM x 1, may repeat dose x 1 after one week in pregnant patients); latent greater than one year (2.4 million units IM weekly for three weeks) Yaws, bejel, and pinta (1.2 million units IM x 1)

Ceftriaxone for treatment of primary syphilis in men: a preliminary study.

Eighteen male patients with primary syphilis were randomly assigned to one of the following treatment schedules: ceftriaxone (3 g in a single intramuscular [im] injection), ceftriaxone (2 g im daily for two days), ceftriaxone (2 g im daily for five days), and benzathine penicillin (2.4 X 10(6) units in a single im injection). The single 3-g dose of ceftriaxone cured three men, one had a sustained response, and one failed to be cured. Of the patients given 2 g of ceftriaxone im daily for two days, three were cured and two had a sustained response. All three men treated with 2 g of ceftriaxone daily for five days had a sustained response. In the group given penicillin, three men were cured, one had a sustained response, and one was lost to follow-up.

Syphilis

Late infections For neurosyphilis, due to the poor penetration of benzathine penicillin into the central nervous system, those affected are given large doses of intravenous penicillin G for a minimum of 10 days. If a person is allergic to penicillin, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular benzathine penicillin for three weeks. Treatment at this stage solely limits further progression of the disease and has a limited effect on damage which has already occurred. Serologic cure can be measured when the non-treponemal titers decline by a factor of 4 or more in 6–12 months in early syphilis or 12–24 months in late syphilis. Jarisch–Herxheimer reaction

Pharmacology_Katzung

Benzathine penicillin and procaine penicillin G for intramuscular injection yield low but prolonged drug levels. A single intramuscular injection of benzathine penicillin, 1.2 million units, is effective treatment for β-hemolytic streptococcal pharyngitis. Given intramuscularly once every 3–4 weeks, it prevents reinfection. Benzathine penicillin G, 2.4 million units intramuscularly once a week for 1–3 weeks, is effective in the treatment of syphilis. Procaine penicillin G was once a commonly used treatment for pneumococcal pneumonia and gonorrhea; however, it is rarely used now because many gonococcal strains are penicillin-resistant, and many pneumococci require higher doses of penicillin G or the use of more potent β-lactams. B. Penicillins Resistant to Staphylococcal Beta-Lactamase (Methicillin, Nafcillin, and Isoxazolyl Penicillins)

InternalMed_Harrison

The WHO-recommended therapy for patients and their contacts is benzathine penicillin G (1.2 million units IM for adults; 600,000 units for children <10 years old). This dose is half of that recommended for early venereal syphilis, and no controlled efficacy studies have been conducted. Definitive evidence of resistance to penicillin is lacking, although relapsing lesions have been reported after penicillin treatment in Papua New Guinea. A recent study in that nation demonstrated equivalence between IM benzathine penicillin G and a single oral dose of azithromycin (30 mg/kg, up to a maximum of 2 g). This 207e-3 finding provided the WHO’s revitalized yaws eradication program with a much easier regimen for use in mass treatment. Although macrolide resistance mutations are common in circulating strains of

InternalMed_Harrison

Early Syphilis Patients and Their Contacts Penicillin G benzathine is the most widely used agent for the treatment of early syphilis; a single dose of 2.4 million units is recommended. Preventive treatment is also recommended for individuals who have been exposed to infectious syphilis within the previous 3 months. The regimens recommended for prevention are the same as those recommended for early syphilis. Penicillin G benzathine cures >95% of cases of early syphilis, although clinical relapse can follow treatment, particularly in patients with concurrent HIV infection. Because the risk of neurologic relapse may be higher in HIV-infected patients, CSF examination is recommended in HIV-seropositive individuals with syphilis of any stage, particularly those with a serum RPR titer of ≥1:32 or a Stage of Syphilis Patients without Penicillin Allergy Patients with Confirmed Penicillin Allergyb Primary, secondary, or early latent

Primary syphilis of the oropharynx: an unusual location of a chancre.

A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti-T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections.

The effectiveness of erysipelas prophylaxis depends on the cumulative dose of benzathine penicillin G.

Erysipelas is an acute infection due to S. pyogenes and is characterized by a high risk of relapses. The number of patients suffering from one or more recurrences varied depending on the study and accounted for between 16% and 47% of the total number of those affected. Antibiotic prophylaxis with the use of penicillin can reduce the risk of recurrence by 47%. A number of 873 patients with erysipelas treated at the Hospital for Infectious Diseases in Warsaw from 2010 to 2018 was enrolled in the study. Benzathine-penicillin G was given intramuscularly at a dose of 1.2 MU or 2.4 MU or 3.6 MU. The earliest moment that prophylactic treatment was administered was the first episode of erysipelas recurrence. The decision to administer the antibiotic and the dose to use was discretionally made by the examining physician. Altogether 104 (11.9%) persons experienced at least one episode of erysipelas recurrence during the study period. A total of 2976 doses of benzathine- penicillin G (BP) were administered. The most common dose was that of 2.4 MU (2380, 80%). The dose of 1.2 MU was given 567 times (19%). The highest dose, <ii.e.</i 3.6 MU, was administered to only 5 patients (8 applications, 0.2%). No effect was shown by either the number of benzathine- penicillin G administered doses (p=0.07) or the median dose (p=0.65), whereas patients without relapse received a statistically higher cumulative dose of the antibiotic (p=0.047). Age was a risk factor of recurrence only in the group of diabetic patients (p=0.03). Benzathine penicillin G given in an appropriate cumulative dose is effective in preventing erysipelas recurrence.

Bacterial Infections of the Oral Mucosa -- Treatment / Management

The chancre and oral lesions in primary syphilis are self-limiting and heal without scar in three to six weeks. A single dose of long-acting benzathine penicillin G (2.4 million units) intramuscular is the drug of choice if primary lesions persist and for secondary syphilis. Tertiary syphilis is also treated with intramuscular benzathine penicillin G once weekly for three to four weeks. The duration of treatment depends on the stage of the disease and its manifestations. Patients who are allergic to penicillin are alternatively treated with doxycycline, tetracycline, or ceftriaxone. Patients diagnosed with syphilis, even if receiving treatment, should abstain from any sexual activity to prevent the spread of the disease. In addition, the sexual partners of a syphilis patient should be notified, tested, and treated accordingly. Post-treatment follow-up is required once every three months for a year using nontreponemal serological tests to ensure the effectiveness of treatment. [5] [19] [24]

Gynecology_Novak

ND, no data. a May be self-applied by patients at home. bExpensive; reserve for patients who have not responded to other regimens. Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year’s duration or of unknown duration should be treated with benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each, at 1-week intervals. All patients with latent syphilis should be evaluated clinically for evidence of tertiary disease (e.g., aortitis, neurosyphilis, gumma, and iritis). Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months. An initially high titer (1:32) should decline at least fourfold (two dilutions) within 12 to 24 months.

Treatment of syphilis: a systematic review.

The incidence of syphilis in the United States is increasing; it is estimated that more than 55,000 new infections will occur in 2014. Treatment regimens are controversial, especially in specific populations, and assessing treatment response based on serology remains a challenge. To review evidence regarding penicillin and nonpenicillin regimens, implications of the "serofast state," and treatment of specific populations including those with neurosyphilis or human immunodeficiency virus (HIV) infection and pregnant women. We searched MEDLINE for English-language human treatment studies dating from January 1965 until July 2014. The American Heart Association classification system was used to rate quality of evidence. We included 102 articles in our review, consisting of randomized trials, meta-analyses, and cohort studies. Case reports and small series were excluded unless they were the only studies providing evidence for a specific treatment strategy. We included 11 randomized trials. Evidence regarding penicillin and nonpenicillin regimens was reviewed from studies involving 11,102 patients. Data on the treatment of early syphilis support the use of a single intramuscular injection of 2.4 million U of benzathine penicillin G, with studies reporting 90% to 100% treatment success rates. The value of multiple-dose treatment of early syphilis is uncertain, especially in HIV-infected individuals. Less evidence is available regarding therapy for late and late latent syphilis. Following treatment, nontreponemal serologic titers should decline in a stable pattern, but a significant proportion of patients may remain seropositive (the "serofast state"). Serologic response to treatment should be evident by 6 months in early syphilis but is generally slower (12-24 months) for latent syphilis. Evidence defining treatment for HIV-infected persons and for pregnant women is limited, but available data support penicillin as first-line therapy. The mainstay of syphilis treatment is parenteral penicillin G despite the relatively modest clinical trial data that support its use.

Nodular secondary syphilis.

Secondary syphilis can have protean clinical manifestations and may present with unusual lesions, which may go unrecognized. We report a case of secondary syphilis with nodular lesions. A 22 year old male presented with nodular and annular skin lesions over the face, back and limbs and condylomata lata lesion at the penoscrotal junction associated with generalized lymphadenopathy, fever and malaise. Prior to onset of these lesions the patient also had history of a painless genital sore, which healed within two weeks. The serology revealed a reactive VDRL(1:64) and positive TPHA. The HIV serology was non-reactive. The patient responded to a single dose of benzathine penicillin, 2.4 million units, given intramuscularly. This case highlights that secondary syphilis may present with nodular lesions and should be suspected in the appropriate clinical setting.

TORCH Complex -- Treatment / Management

Syphilis must be diagnosed and treated immediately. Expectant mothers should be tested during pregnancy and, if positive, treated. [25] Treatment of the neonate will depend on whether the mother was treated appropriately during pregnancy. Normal neonates born to mothers adequately treated during pregnancy and greater than four weeks before delivery or have a non-reactive RPR but were born to mothers not treated properly should receive a single intramuscular injection of benzathine penicillin G (50,000 U/kg), although no evaluation is required or recommended. Infants with serologic tests that confirm congenital syphilis should receive aqueous penicillin g (200,000 to 300,000 units/kg/day IV, administered as 50,000 units/kg every 4 to 6 hours for ten days). If the child has a negative evaluation for clinical and laboratory evidence of syphilis, treatment with up to 3 weekly doses of benzathine penicillin G (50,000 U/kg IM) can be considered. [21]

Treatment of secondary syphilis: an evaluation of 204 patients.

Our recommended treatment schedule for secondary syphilis is intramuscular benzathine penicillin G, 2.4 million units weekly for two consecutive weeks. If the patient is allergic to penicillin, we recommend that 2 gm of oral tetracycline be given each day for 12 days. Two hundred and four patients with secondary syphilis were treated with these schedules; 165 were given benzathine penicillin G and 39 received tetracycline. All of the patients were cured clinically and all achieved seronegativity within 24 months. There was a direct correlation between the duration of the rash and the secondary lesions that the patients exhibited. Patients who presented early in the course of illness tended to have macular and maculopapular lesions, whereas those who appeared later were more likely to have papular of pustular lesions. The serologic response to treatment was correlated with the duration of the rash and the appearance of the secondary lesions. Patients whose rash was of short duration and those with macular and maculopapular lesions became seronegative sooner than those patients whose rash was of longer duration and who had papular or pustular lesions.

Syphilis Ocular Manifestations -- Treatment / Management

Primary and secondary syphilis is treated with a single dose of intramuscular (IM) penicillin G benzathine 2.4 million units, or procaine penicillin, 2.4 million units IM daily, and probenecid, 1 g orally 4 times a day for 14 days. In patients who are allergic to penicillin, doxycycline 100 mg orally twice daily for 14 days or ceftriaxone 1 to 2 gm IM or intravenously (IV) daily for 10 to 14 days or tetracycline 100 mg orally 4 times daily for 14 days, can be used. Azithromycin has also been used. [29] [30] Latent and tertiary syphilis, including neurosyphilis, is treated with aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hourly for 10 to 14 days, or benzathine penicillin G, 2.4 million units IM weekly for 3 weeks. Ceftriaxone and azithromycin also have been used in patients allergic to penicillin. [31]