Chiefs’ Inquiry Corner-5/31/22

May 31, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 Looks promising! Tebipenem pivoxil hydrobromide is an oral carbapenem with broad-spectrum activity against multidrug resistant, gram-negative bacteria that was recently compared to intravenous ertapenem for the treatment of complicated urinary tract infection or acute pyelonephritis. In a phase 3, international, doubt-blind, double-dummy trial, 1372 hospitalized adults with complicated urinary tract infection or acute pyelonephritis were randomly assigned to receive oral tebipenem pivoxil hydrobromide (+ dummy intravenous “ertapenem”) or intravenous ertapenem (+ dummy oral “tebipenem”) for 7-10 days, or up to 14 days in people with bacteremia. The primary endpoint was overall response rate (a composite of clinical cure, which was defined as complete resolution or improvement of signs/symptoms present at baseline, and no development of new symptoms, and microbiologic response, which was defined as reduction in the baseline uropathogen to <10^3 CFU/mL and negative repeated blood culture if positive at baseline). Tebipenem was shown to have noninferior response rate when compared to ertapenem, and was also noninferior to ertapenem with regard to rate of clinical cure (a secondary endpoint). Rate of adverse events in the two groups was nearly identical, with diarrhea and headache the two most common side effects. While further trials are needed, including those examining treatment of infection from sources other than the genitourinary system, tebipenem shows promise as another therapeutic option in the battle against MDRO genitourinary infections.

References: Oral Tebipenem Pivoxil Hydrobromide in Complicated Urinary Tract Infection
 Monkeypox virus is a member of the genus Orthopoxvirus, which also includes the virus responsible for smallpox (variola). The major defining clinical characteristics of monkeypox infection is the eruption of a rash consisting of lesions that are firm, deep, well-circumscribed, and umbilicated, typically first appearing on the face and progressing in a centrifugal distribution (that is, in a distribution that spreads outward from the chest, with greater involvement of the face and extremities, in comparison to a centripetal distribution, often seen with varicella [chickenpox], whereby the rash is distributed inwards, towards the chest/trunk). The lesions often initially present as first macular, then papular, and then finally vesicular and pustular, and can involve the palms of the hands and soles of the feet (varicella, it should be noted, rarely involves lesions on the palms or soles). There are often lesions present in the oropharynx. Lymphadenopathy (maxillary, cervical, and/or inguinal), with lymph nodes firm, tender, and sometimes even painful, frequently develops prior to or simultaneously with the rash; such lymphadenopathy is not seen with smallpox infection, offering a helpful clinical clue in differentiating the two infections, as the skin lesions themselves can be indistinguishable between smallpox and monkeypox. There is also often an initial prodrome, 1-4 days prior to rash eruption, that consists of fever, generalized headache, and fatigue. The incubation period after infection of monkeypox is approximately 1 week-17 days after exposure. Patients are no longer considered capable of transmitting infection once their lesions have crusted over and the crusts have fallen off. The most common long-term sequelae of monkeypox infection is pitted scarring, which can have significant impacts on quality of life and psychological health. For those who are not vaccinated, severe complications and sequelae are more common than in those who are vaccinated, and include bronchopneumonia, as well as dehydration from vomiting and diarrhea. Mortality rate can be as high as ~10% in people who are not vaccinated; children are at risk of more severe forms of the disease.

References: Human monkeypox
 Paroxysmal finger hematoma (PFH), also known as blue finger syndrome, is a benign condition of incompletely understood etiology. First described by German internist Dr. Walter Achenbach in 1958, the condition involves the appearance of bluish-purple discoloration to the volar aspect of the palm, or to the fingers, without obvious trauma to the area, and can involve prodromal symptoms, such as pain, tingling, and itching, that occur from minutes to hours prior to the appearance of the discoloration. This phenomenon most commonly occurs in postmenopausal women and while the exact underlying pathophysiology has not been elucidated, is thought to be at least in part due to thinning of the veins in the fingers and palms, with subsequent leakage of blood into the surrounding dermis, in response to increased pressure to the area (such as from carrying bags). When the fingers are affected, the distal phalanges and nail bed are notably spared (in contrast to discoloration caused by ischemic disease). The discoloration typically resolves within 3-6 days, and the typical stages of ecchymosis resorption are characteristically absent. This is a benign condition and, when diagnosed, can be treated with reassurance. However, it remains a diagnosis of exclusion, as a variety of other conditions can lead to discoloration of the fingers, and the differential diagnosis (which includes, among others, Raynaud’s syndrome, acute upper limb ischemia, and vasculitic disease including thromboangiitis obliterans) should be considered before making the diagnosis of Achenbach syndrome.

References: Achenbach syndrome (paroxysmal finger hematoma)