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Evaluation of patients presenting with acute erythema nodosum should include a careful history (including drug exposures) and physical examination for prior upper respiratory infection or diarrheal illness, symptoms of any deep fungal infection endemic to the area, a chest radiograph, a PPD, and two consecutive ASO/ DNAseB titers at 2- to 4-week intervals If no underlying cause is found, only a small percentage of patients will go on to develop a significant underlying illness (usually sarcoidosis) over the next year



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A furuncle (boil) is a deep-seated infection (abscess) involving the entire hair follicle and adjacent subcutaneous tissue The most common sites of occurrence are the hairy parts exposed to irritation and friction, pressure, or moisture Because the lesions are autoinoculable, they are often multiple Diabetes mellitus (especially if using insulin injections), injection drug use, allergy injections, and HIV disease all increase the risk of staphylococcal infections by increasing the rate of nasal carriage A carbuncle consists of several furuncles developing in adjoining hair follicles and coalescing to form a conglomerate, deeply situated mass with multiple drainage points

Sout 150,000,000 W = = 394 A 3VLL 3 ( 220, 000 V )





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Some cases of endocarditis occur after dental procedures or operations involving the upper respiratory, genitourinary, or intestinal tract Prophylactic antibiotics are given to patients with predisposing congenital or valvular anomalies who are to have any of these procedures (Tables 33 3 and 33 4) Current recommendations are given in Table 33 5

Empiric regimens for endocarditis while culture results are pending should include agents active against staphylococci,

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High Risk Prosthetic cardiac valves, mechanical, bioprosthetic, or homograft Previous bacterial endocarditis Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot) Surgically constructed systemic pulmonary shunts or conduits Moderate Risk Most congenital cardiac malformations (other than those listed above and below) Rheumatic heart disease Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation2 Negligible Risk3 Isolated secundum septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus(without residua beyond 6 months) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvular regurgitation Physiologic, functional, or innocent heart murmurs Previous Kawasaki disease without valvular dysfunction Rheumatic fever without valvular dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators This table lists selected conditions and is not meant to be all-inclusive Mitral regurgitation determined by the presence of a murmur or by echoDoppler Men older than 45 years may warrant prophylaxis even without a consistent systolic murmur Mitral valve prolapse associated with thickening or redundancy of the valve leaflets may be associated with an increased risk for bacterial endocarditis 3 Risk no greater than in the general population; endocarditis prophylaxis not recommended

patient with IgE-mediated allergy to penicillin, vancomycin alone, 15 mg/kg intravenously every 12 hours for 4 weeks, should be administered Endocarditis caused by viridans streptococci with an MIC > 05 mcg/mL or by nutritionally deficient streptococci should be treated the same as enterococcal endocarditis (see below)

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Endocarditis caused by S pneumoniae, S pyogenes (group A streptococcus), or groups B, C, and G streptococci is unusual S pneumoniae sensitive to penicillin (MIC < 01 mcg/mL) can be treated with penicillin alone, 2 3 million units intravenously every 4 hours for 4 6 weeks Vancomycin should be effective for endocarditis caused by strains resistant to penicillin Group A streptococcal infection can be treated with penicillin, ceftriaxone, or vancomycin for 4 6 weeks Groups B, C, and G streptococci tend to be more resistant to penicillin than group A streptococci, and some experts have recommended adding gentamicin, 1 mg/kg intravenously every 8 hours, to penicillin for the first 2 weeks of a 4- to 6-week course Endocarditis caused by S bovis is associated with liver disease and gastrointestinal abnormalities, especially colon cancer Colonoscopy should be performed to exclude the latter

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