Research Pipeline

Point of Care testing for bacterial vs. viral infections…


One Flu Over the Cuckoo’s Nest

Unlike some of my colleagues, I am not one to rally the troops and go on the offensive about the benefits of immunizations. I prefer to think I fall somewhere in the middle. While I fully support the benefits of immunizations, I also support a person’s right to choose. Consequently, I rarely get on a soap box and pontificate on the topic. However, given this year’s flu season to date, I find I must abandon my usual centrist stance on the topic. Though admittedly anecdotal, I’m hoping what I’m about to relate will make the reader capable of making a more informed decision on the issue.

While the politicians in Washington spent a good part of Fall 2014 scaring the country about an ebola outbreak that never happened, the influenza virus has decided to take advantage of the distraction and do some real damage. I have seen more influenza cases and admitted more patient’s for the flu than possibly in my last ten years of practicing medicine. All of these patients have one thing in common:

None of them had a flu shot.

I’ll say that again, none of them had a flu shot. I know this because I ask my patients (or their respective parent) and it’s one of those questions that people have little reason to lie about. Now, while most adults who contract the flu will be fine, with or without being prescribe an anti-viral, the bigger concern comes with infants, children, elderly, and the immunocompromised. These patients are at an increased risk of complications and death from the flu. As already stated, I have admitted more patient’s for influenza this year than the past ten. These patients, particularly infants and elderly, are presenting to us extremely sick. Dehydration is common. Co-existing pneumonia’s are not unusual. These populations are unable to handle the flu well and usually contract it from an adult who can.

Is the flu vaccine a guarantee? No, there are none. IT IS our best defense against getting the flu and the complications that can arise from it. If you want a guarantee, buy a toaster. Given that we are well into the flu season, if you have already been exposed to the flu virus before getting the vaccine, you may still get the flu. However, the vaccine will NOT make the illness worse.

As I said, I’m not going to go on an exhaustive campaign and demand everyone get the flu shot. This is still America, you can still make choices. All I ask is that you seriously consider the information I have presented here and consider the health of not only yourself but of those around you. I hope that you will see the benefit and protection from getting the flu vaccine.

Dermatology Clinic

A 25 year old male presents to the Emergency Department complaining of a rash to his left side. The patient stated he first noticed it after waking up 3 hours before coming to the ER. The patient denied any associated symptoms including pain, pruritus, fever, chills, myalgias, arthralgias, fatigue, headache, weakness, or swelling of lymph nodes. He further denied any new soaps, detergents, foods, medications, or topical products. ROS was otherwise negative, the patient denied no prior medical problems. The patient did report working outdoors as a landscaper but denied any known insect bites, recent wounds to affected area, or past contact allergies to plants.

Clinically, the patient was a well developed, well nourished, 25 year old male in no distress or discomfort, and appeared in excellent health. Vital signs showed he was afebrile and normotensive with a normal pulse rate. His exam was unremarkable save for the rash that appeared as follows:


I’m sure most will recognize the large bull’s eye pattern to the rash, which combined with the patient’s history of working outdoors created the concern for Lyme Disease. The patient was started on the appropriate course of Doxycycline, Lyme Titers were sent which ultimately returned positive as well as follow up testing.

While Lyme Disease is not uncommon and it’s associated bull’s eye rash is usually easily identified, I felt this case was worthy of note to make some finer points about the disease.

1) Lack of Symptoms: While we all learn about the constitutional symptoms (arthralgia, fevers, etc.) of Lyme Disease, it is not necessary to have them all as demonstrated by this case.

2) Time of Onset of Rash: While the average time of onset of a bull’s eye rash is 7 days, it can occur anywhere from 3 to 30 days after a tick bite. Combined with the fact that Lyme Tests typically will not seroconvert to positive for about 3 weeks and this patient tested positive from the first test, this patient did not develop the bull’s eye rash until roughly day 21 post exposure.

3) Size/Location of Rash: It can be easy to assume that the bull’s eye rash will be smaller in size. Indeed a simple google image search show most (not all) of the bull’s eye rashes to be smaller in size. In addition, they are seen on expected locations such as extremities and trunk, as with the case above. However, since the rash first appears at the site of the tick bite, the rash can occur anywhere including less thought about places such as the groin or scalp, the latter of which can be obstructed by hair.

Recall on tattoo ink due to bacterial contamination

To all my friends and colleagues who have tattoos and especially those who are tattoo artists, please weigh in with what you know about this.

A two way street: the clinician / patient relationship

The attached article is much more than about vaccines. The concept that a clinician’s patient needs to afford him or her a minimum level of respect and trust is paramount and applies to all aspects of the patient / clinician relationship. It’s not the same as “Doctor knows best”. Yet, as the author points out, there needs to be a degree of respect for the clinicians education and experience and that we are not simply an official to “rubber stamp” what the patient wants. When patients come in demanding an antibiotic or a CT scan for their illness, it needs to be understood that there are times the treatment they want is sometimes entirely inappropriate and can even be harmful to them. And in the case of vaccines, the withholding of treatment can be detrimental.