A patient presents to the emergency center with a 6-h history of fever to 38.9°C (102°F). Her mother reports that the patient appeared to be feeling poorly, that she had been eating less than normal, and that she vomited once. About 2 h prior to arrival at the emergency room, the mother states that she noted a few purple spots scattered about the body on the patient, especially on the buttocks and legs. On the 30-min ride to the emergency room, the purple areas spread rapidly and became coalesced in areas, and the patient is now obtunded. Which of the following is the most likely diagnosis?
a. Henoch-Schönlein Purpura
b. Toxic shock syndrome caused by Staphylococcus aureus
d. Rocky Mountain spotted fever
the answer is below…
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently.
The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual’s knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.
All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual’s ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
The correct answer is e; Meningococcemia.
The patient in the question likely has meningococcemia, but Rocky Mountain spotted fever is also a consideration. Rocky Mountain spotted fever and meningococcemia can present in a similar fashion, although a rapid course as outlined in the question is more common of meningococcemia. Meningococcemia can be complicated by a variety of disorders, including meningitis, purulent pericarditis, endocarditis, pneumonia, otitis media, and arthritis. (Arthritis associated with meningococcemia may be mediated by an immune mechanism rather than by bacterial invasion of the joint.) The potent endotoxin of the causative organism, Neisseria meningitidis, can induce shock, disseminated intravascular coagulation with associated hemorrhaging, and acute adrenal failure caused by localized intra-adrenal bleeding; these reactions can be collectively referred to as the Waterhouse-Friderichsen syndrome. Vaccines against N. meningitidis groups A, C, Y, and W135 are now available, and the age range of patients to whom they are recommended is evolving. Prophylaxis with sulfadiazine for sensitive organisms or with rifampin for those in close contact with affected persons is recommended. In contrast, Rocky Mountain spotted fever is often a more indolent infection, with a rash developing days after the onset of the fever and other symptoms. This course is not invariable, however, and antibiotic therapy for the patient for whom Rocky Mountain spotted fever and meningococcemia cannot be differentiated should not be delayed.
Measles presents in a child with a several-day history of malaise, fever, cough, coryza, and conjunctivitis followed by the typical, widespread, erythematous, maculopapular rash. Koplik spots, white pinpoint lesions on a bright red buccal mucosa often in the area opposite his lower molars, appear transiently and are pathognomonic. Henoch-Schönlein purpura can have a distribution of rash that appears purpuric (actually a vasculitis) over the lower extremities, but its rapid progression and shocklike state as presented in the question would be distinctly unusual.