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General lnternal Medicine Acute Sialadenitis Diagnosis Symptoms include sudden onset of acute pain and swelling of the affected salivary gland, which may be accompanied by fever. Sialadenitis typically has a bacterial cause, most commonly Staphylococcus oureus; Iess common causes include viral infection (mumps, CMV HIV), mycobacterial infection, and recent radiation therapy. Physical examination often reveals tenderness and erythema over the affected gland. Stones may be palpated and are typically tender, small, and hard. Manual palpation may result in pus exuding from the duct's orifice that can be cultured to direct antibiotic therapy. Treatment Warm compresses and sialagogues (sour candies or vitamin C lozenges); salivary gland massage; increased fluid intake; oral hygiene; and, in cases ofbacterial sialadenitis, antibiotics are indicated. Pharyngitis Diagnosis Use the 4-point Centor criteria to stratifii adult patients according to risk of group A streptococcal pharyngitis . fever (subjective) . absenceofcough . tender anterior cervical lymphadenopathy . tonsillar exudates Management is based on the number of Centor criteria present: r <2: neither test nor treat with antibiotics . >3: obtain a rapid antigen detection test (RADT); management is based on results Fusobqcterium necrophorum infection should be considered in adolescents and young adults with a negative RADT and an unusually prolonged and severe pharyngitis. F. necrophorum is the causative agent of Lemierre syndrome, septic thrombophle- bitis of the internal jugular vein resulting in metastatic pulmonary infections. Treatment Select oral penicillin for 10 days. Choose a macrolide for patients allergic to penicillin. F. necrophorum is treated with ampicillin- sulbactam. Oral Infections and Dental Disease Diagnosis Dental caries are recognized by stained pits and fissures. Pulpitis occurs when the erosion extends down to the pulp cavity. If untreated, the erosion can affect the root or cause periodontitis. 168

General lnternal Medicine Ludwig angina is a life threatening infection of the floor of the mouth causing submandibular swelling and edema, drooling, neck pain, dysphagia, or dysphonia. Ludwig angina can cause airway obstruction owing to supraglottic edema. The causative pathogen is usually Viridans streptococci. Diagnostic studies include urgent Cl blood cultures, and airway management. Necrotizing ulcerative gingivitis is characterized by halitosis, oral pain, and ulcerated and necrotic areas of the tonsils and gingiva with red irregular edges that may create a grayish pseudomembrane that bleeds if scraped. Treatment Pulpitis is treated with removal of caries and a dental filling. Periodontitis is treated by root canal. Ludwig angina is treated with broad-spectrum antibiotic therapy and, if indicated, surgical drainage. Necrotizing ulcerative gingivitis is treated with oral antibiotics, chlorhexidine rinses, and, if severe, debridement. Dermatologic Signs of Systemic Disease $TUDY TABLE: lmportant Associations lf you see this... Consider diagnosis of... Porphyria cutanea tarda, palpable purpura Hepatitis C Severe or recalcitrant seborrheic dermatitis or abrupt onset of lnitial manifestation of HIV infection severe psoriasis Erythema nodosum lBD, TB, sarcoidosis, coccidioidomycosis, streptococcal infection; look particularly for Lofgren syndrome (bilateral hilar lymphadenopathy, erythema nodosum, and lower extremity arthralgia) Dermatitis herpetiformis Celiac disease Livedo reticularis (see Cardiovascular Medicine section for Atheroemboli (previous vascular catheterization), thrombophilia, image) hyperviscosity syndrome, vasculitis I hToderma gangrenosum lBD, inflammatory arthritis, lymphoproliferative disorders

Dermatologic Signs of Systemic Disease $TUDY TABLE: lmportant Associations lf you see this... Consider diagnosis of... Porphyria cutanea tarda, palpable purpura Hepatitis C Severe or recalcitrant seborrheic dermatitis or abrupt onset of lnitial manifestation of HIV infection severe psoriasis Erythema nodosum lBD, TB, sarcoidosis, coccidioidomycosis, streptococcal infection; look particularly for Lofgren syndrome (bilateral hilar lymphadenopathy, erythema nodosum, and lower extremity arthralgia) Dermatitis herpetiformis Celiac disease Livedo reticularis (see Cardiovascular Medicine section for Atheroemboli (previous vascular catheterization), thrombophilia, image) hyperviscosity syndrome, vasculitis I hToderma gangrenosum lBD, inflammatory arthritis, lymphoproliferative disorders Acanthosis nigricans (hyperpigmentation and velvety Diabetes hyperkeratosis on flexural surfaces) Xanthomas Familial hypercholesterolemia Mechanic's hands (hyperkeratotic, fissured skin on the palms) Dermatomyositis/antisynthetase syndrome (myositis, Raynaud syndrome, interstitial lung disease with anti-Jo-1 antibodies) Heliotrope rash Dermatomyositis DON'T BE TRICKED . EcthymagangrenosumisacharacteristicskinlesionofPseudomonosandothersystemicbacterial,fungal,orviral infections. It begins as a painless, erythematous macule and quickly develops into a large necrotic ulcer' It is usually seen in an immunocompromised patient.

Heliotrope rash Dermatomyositis DON'T BE TRICKED . EcthymagangrenosumisacharacteristicskinlesionofPseudomonosandothersystemicbacterial,fungal,orviral infections. It begins as a painless, erythematous macule and quickly develops into a large necrotic ulcer' It is usually seen in an immunocompromised patient. Eczemas Diagnosis Acute eczematous dermatitis is characterized by dry skin, intense pruritus with erythematous papules and vesicles, crusting' and oozing. Lichenification (skin thickening from chronic scratching, with scaling and fissuring) defines chronic eczema' 169