Rosen & Barkin's 5-Minute Emergency Medicine Consult (782 page)

Disseminated cases in immunocompromised patients may require admission

Most patients can be treated as outpatients

• All medication-based therapies require follow-up and subsequent dosing. Should not initiate treatment unless follow-up can be secured
  
• For treatment failures, referral to PMD or dermatology should be made for alternative treatment options
  
• Refer sexually active teenage girls to pediatrician or primary care for HPV vaccination
  

• Pain, burning, redness, or other changes in symptoms require prompt re-evaluation
  
• Arrange follow-up with appropriate provider: Pediatrician, gynecologist, dermatologist, primary care physician
  

• Pregnancy test must be done before initiation of medical therapy
  
• HPV vaccine does not protect from all forms of HPV, just those most commonly associated with cervical cancer
  
• Consider sexual assault in children with anogenital warts
  

• Gilson RJ, Ross J, Maw R, et al. A multicentre, randomised, double-blind, placebo controlled study of cryotherapy versus cryotherapy and podophyllotoxin cream as treatment for external anogenital warts.
  Sex Transm Infect
  . 2009;85(7):514–519.
  
• Herman BE, Corneli HM. A practical approach to warts in the emergency department.
  Pediatr Emerg Care
  . 2008;24:246–251.
  
• Hutchinson DJ, Klein KC. Human papillomavirus disease and vaccines.
  Am J Health Syst Pharm
  . 2008;65:2105–2112.
  
• Kwok CS, Gibbs S, Bennett C, et al. Topical treatments for cutaneous warts.
  Cochrane Database Syst Rev.
  2012;12(9):CD001781.
  
• Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP).
  MMWR Recomm Rep
  . 2007;56:1–24.
  
• Workowski KA, Berman SM. Centers for Disease Control and Prevention, Sexually transmitted diseases treatment guidelines,
  Clin Infect Dis
  . 2011;53(suppl 3):S59–S63.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Herpes, Genital
  
• HIV/AIDS
  
• Molluscum Contagiosum
  

CODES

• 078.10 Viral warts, unspecified
  
• 078.12 Plantar wart
  
• 078.19 Other specified viral warts
  

BASICS

• Defined as a decrease in physical strength or energy
  
• Often multifactorial
  
• Distinguish neuromuscular disorder vs. non-neuromuscular disorder
  
• Categories of neuromuscular disorders:
  
  • Upper motor neuron (UMN) lesions:
    
    • Deep tendon reflexes (DTR) increased
      
    • Plantar reflexes upgoing
      
    • Increased muscle tone
      
    • Muscle atrophy absent
      
  • Lower motor neuron (LMN) lesions:
    
    • DTRs decreased to absent
      
    • Plantar reflexes absent or normal
      
    • Decreased muscle tone
      
    • Muscle atrophy present
      
    • Fasciculations
      
  • Neuromuscular junction (NMJ) lesions:
    
    • DTRs normal
      
    • Plantar reflexes normal or absent
      
    • Decreased muscle tone
      
• Categories of non-neuromuscular disorders:
  
  • Infectious
    
  • Endocrine
    
  • Metabolic
    
  • Cardiac
    
  • Rheumatologic
    
  • Toxic
    
  • Psychiatric
    

• Neuromuscular disorders:
  
  • UMN lesions:
    
    • Multiple sclerosis
      
    • Amyotrophic lateral sclerosis (mixed)
      
    • Transverse myelitis
      
    • Poliomyelitis
      
  • LMN lesions:
    
    • Guillain–Barré syndrome
      
    • Toxic neuropathies
      
    • Impingement syndromes
      
    • Diphtheria
      
    • Porphyria
      
    • Seafood toxins
      
  • NMJ lesions/others:
    
    • Myasthenia gravis
      
    • Lambert–Eaton syndrome
      
    • Botulism
      
    • Periodic paralysis
      
    • Tick paralysis
      
• Non-neuromuscular disorders:
  
  • Dehydration
    
  • Anemia
    
  • Electrolyte imbalances
    
  • Malignancy
    
  • Cerebrovascular accident
    
  • Head or neck trauma
    
  • Myocardial ischemia
    
  • Infection/sepsis:
    
    • UTI
      
    • Pneumonia
      
    • Meningitis
      
    • Mononucleosis
      
    • HIV
      
    • Arborviruses
      
  • Endocrine abnormalities:
    
    • Hypothyroidism
      
    • Adrenal crisis
      
    • Periodic paralyses
      
  • Rheumatologic disorders:
    
    • Systemic lupus erythematosus
      
    • Polymyalgia rheumatica
      
  • Toxins:
    
    • Medications
      
    • Environmental
      
    • Carbon monoxide poisoning
      
    • Cocaine
      
    • Alcohol
      

DIAGNOSIS

• Altered physical strength:
  
  • Assessment of strength:
    
    • 1: No contraction
      
    • 2: Active movement with gravity eliminated
      
    • 3: Active movement against gravity
      
    • 4: Active movement against gravity and resistance
      
    • 5: Normal power
      
  • Change in muscle tone:
    
    • Flaccidity
      
    • Spasticity
      
    • Rigidity
      
  • Abnormal DTRs
    
  • Abnormal plantar reflexes
    
  • Muscle atrophy:
    
    • Difference of >1 cm in the leg and thigh and >0.5 cm in the forearm and arm
      
• Systemic findings:
  
  • Weakness
    
  • Fatigue
    
  • Dizziness
    
  • Paresis
    
  • Paresthesias
    
  • Hoarse voice
    
  • Dysphagia
    
  • Visual changes
    
  • Confusion
    
  • Associated symptoms:
    
    • Fever
      
    • Chest pain
      
    • Dyspnea
      
    • Cough
      
    • Weight loss
      
    • Rash
      
    • Dysuria
      
    • Upper respiratory infection symptoms
      

• Review of medications
  
• Clinical suspicion gathered through history and physical exam guides further testing:
  
  • Generalized vs. focal
    
  • Acute vs. chronic
    
  • Proximal vs. distal
    
  • Ascending vs. descending
    
  • Symmetric vs. asymmetric
    
  • Improved vs. worsened with activity
    

Diagnostic testing should be broad unless history and physical exam identify the cause of weakness.

• Serum glucose
  
• CBC
  
• Electrolytes
  
• BUN/creatinine
  
• Toxin screen
  
• Urinalysis
  
• Thyroid function tests (rule out hypothyroidism)
  
• ESR (rule out rheumatologic cause)
  
• Carboxyhemoglobin (rule out CO poisoning)
  
• Troponin/CK-MB (rule out cardiac ischemia)
  
• Digoxin level (rule out digoxin toxicity)
  

• EKG (rule out acute coronary syndrome [ACS]/arrhythmia)
  
• CXR (rule out pneumonia)
  
• CT/MRI head (rule out intracranial pathology)
  

• Bedside spirometry:
  
  • Forced vital capacity, negative inspiratory force, peak expiratory flow rate
    
  • May identify those with impending ventilatory failure
    
• Lumbar puncture:
  
  • In suspected Guillain–Barré syndrome:
    
    • Albumin-cytologic dissociation in CSF (protein >400, WBC <10) is virtually diagnostic.
      
• Tensilon test:
  
  • Distinguishes myasthenic crisis from cholinergic crisis in myasthenia gravis
    

• Physiologic causes of weakness:
  
  • Simple fatigue:
    
    • Excessive physical activity
      
    • Inadequate rest
      
    • Excessive or inadequate diet
      
    • Pregnancy
      
• Psychiatric causes of weakness:
  
  • Anxiety/depression
    
  • Dependent personality
    
  • Hypochondriasis
    
  • Chronic fatigue syndrome
    
  • Fibromyalgia
    
  • Malingering