The Lean Antibiotic Mantra

Sometimes Nothing Is Better Than Something

Neil Gaffin, MD; Brad Spellberg, MD


April 09, 2018

Given the patient's age, her tophaceous-appearing Bouchard nodes, worsening azotemia (on diuretics), recent history of trauma, a progressive course, and no response to empiric antibiotics, a crystalline-induced arthropathy precipitated by trauma was suspected.[11]

A serum uric acid measurement, which can lend support to the diagnosis but is neither diagnostic nor required to establish it, was not ordered. Indeed, the serum uric acid level can be normal in nearly 50% of patients during an acute attack.[12]

The diagnosis was established by aspirating bloody/chalky fluid containing negatively birefringent monosodium urate crystals (Figure 3) from the tophaceous swelling over the second MCP joint. She continued to improve and was discharged with the recommendation to follow up with her rheumatologist.

Inflammatory arthropathies, such as gout and pseudogout, are among the many mimickers of cellulitis, but treatment is with anti-inflammatories, not antibiotics.[13]

Figure 3. Progression of improvement in the left hand after treatment with corticosteroids and aspirated monosodium urate crystals. The third image on the right shows urate crystals under the polarizing microscope.

A Young Woman With Cough

A 29-year-old previously healthy woman presented to the ED with 3 days of worsening cough associated with fever and chills. There was no recent travel history. She was in no respiratory distress. Her temperature was 103.1°F. Oxygen saturation on room air was 98%. Chest exam was clear. The WBC count was 6300 cells/µL, without left shift.

Chest x-ray revealed a "dense left lower-lobe consolidating infiltrate" (Figure 4). Chest CT indicated left lower-lobe consolidation (Figure 5).

The procalcitonin level sent from the ED was 0.06 ng/mL, and a respiratory pathogen PCR assay was positive for enterovirus/rhinovirus. After admission to the hospital, the patient began ceftriaxone and doxycycline for community-acquired pneumonia. She remained clinically stable and was afebrile the next day. The procalcitonin level on the second hospital day was 0.04 ng/mL.

Figure 4. Chest x-ray revealing left lower-lobe consolidation.

Figure 5. Chest CT revealing left lower-lobe consolidation.


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