An Emergency Medicine Broadsheet
·Phoenix·
Est. MMXXVI
Blue Fish Med · Today's Topic
Critical Fungal Infection
Invasive fungal infection is a time-sensitive diagnosis: delays allow angioinvasion, tissue necrosis, and death. The emergency job is to recognize the host risk, start the right antifungal, and move fast on source control.
A 58-year-old man with a shaved head and an IV pole clicking beside him keeps rubbing at the bridge of his nose, where the skin looks dusky and wet. He has had fever, facial pain, and a thin black crust that seemed small yesterday but now reaches toward his cheek. His wife says he was “fine” until a week of profound weakness after chemotherapy, and now his right eye barely opens. The nurse is waiting for the next order, but the clock is already winning.
— What’s your move? Read on.
Before you read
Who needs amphotericin and the OR now, not after imaging?
Which immunocompromised patient with fever is sick enough to treat empirically?
When to Think of It
Think of this at the bedside in neutropenia, transplant, prolonged steroids, uncontrolled diabetes, or profound immunosuppression with fever plus focal invasive signs: black eschar, necrotic tissue, pleuritic pain, hemoptysis, focal neuro deficits, sinus/orbital pain, persistent sepsis without bacterial source. Mucormycosis, invasive aspergillosis, candidemia, and endemic fungal syndromes can all present critically, but angioinvasive mold with necrosis is the classic emergency.
Sick or Not Sick
The fork is stable vs. invasive/organ-threatening. Any hemodynamic instability, orbital/CNS involvement, necrosis/eschar, neutropenic sepsis, or pulmonary hemorrhagic lesion = treat as critically ill and escalate immediately.
The First Fifteen Minutes
If neutropenic fever or septic shock in a high-risk host → broad-spectrum antipseudomonal antibiotics now: cefepime 2 g IV q8h, or piperacillin-tazobactam 4.5 g IV q6h, or meropenem 1 g IV q8h, because bacterial coinfection is common and death is often bacterial while you chase fungus.
If invasive mold strongly suspected (black eschar, orbital/sinus invasion, necrotic lesion, hemoptysis in immunocompromised) → liposomal amphotericin B 5 mg/kg IV daily now; for suspected mucormycosis, many use 5–10 mg/kg IV daily, because it is the fastest reliable broad anti-mold agent and covers Mucorales.
If invasive aspergillosis is more likely and mucor less likely → voriconazole 6 mg/kg IV q12h x2 doses, then 4 mg/kg IV q12h (or 200–300 mg PO q12h when appropriate), because it is first-line for Aspergillus and penetrates tissue well.
If candidemia or disseminated candidiasis is likely in a sick inpatient → echinocandin now: micafungin 100 mg IV daily, caspofungin 70 mg IV load then 50 mg IV daily, or anidulafungin 200 mg IV load then 100 mg IV daily, because it rapidly clears bloodstream Candida and is fungicidal.
If adrenal crisis-like shock with suspected disseminated fungal sepsis and refractory hypotension → fluids, vasopressors, and stress-dose steroids only if otherwise indicated, because the fix is resuscitation plus source control, not empiric steroids.
If severe hypoxemia or airway threat from fungal sinus/orbital disease → secure airway early, because edema and necrosis can make later intubation impossible.
Consult ENT/ophthalmology/neurosurgery/surgery emergently for biopsy/debridement, because histology and source control are often life-saving.
Definitive Care & Disposition
Definitive treatment is organism- and site-specific: debridement for mucormycosis, antifungal tailoring once cultures/histopathology return, and reversal of immunosuppression when possible. Admit all suspected invasive fungal infections; ICU for shock, respiratory failure, CNS/orbital involvement, or rapidly progressive necrosis. Send blood cultures, fungal markers where useful, CT/MRI for extent, and biopsy any accessible lesion; start therapy before confirmation when suspicion is high.
How This One Kills
The fatal error is dismissing necrotic sinus disease or persistent febrile neutropenia as “just infection” and waiting for culture proof. Angioinvasive fungi thrombose vessels, so tissue dies while the patient looks only mildly worse—until they crash.
The Differential — What Else Looks Like This
Bacterial necrotizing soft tissue infection — pain out of proportion and subcutaneous gas point more bacterial; confusing it delays both surgical debridement and the correct antifungal if the lesion is actually invasive mold.
Acute bacterial sinusitis/orbital cellulitis — diffuse erythema without black eschar or cranial nerve deficits argues bacterial; missing mucor risks vision loss and brain invasion.
Vasculitis or pyoderma gangrenosum — inflammatory ulcers can look necrotic, but immunosuppression plus rapid angioinvasive spread favors fungus; mislabeling as inflammatory disease can worsen outcomes if steroids are given.
Melanoma or benign eschar/scab — pigment or crust without systemic illness is misleading; confusion delays biopsy and antifungal therapy.
The Second-Day Story
In older adults, diabetics, or partially treated immunocompromised patients, the “classic” picture softens: fever may be absent, pain may be vague, and the lesion may look like a simple ulcer or sinus headache. The clue is trajectory—rapid progression, tissue duskiness, cranial neuropathies, refractory sepsis, or pleuritic pulmonary disease in the right host should trigger invasive fungal thinking even when the skin or sinus exam seems unimpressive.
Back to Our Patient
Back to our patient: the 58-year-old man with chemotherapy-associated immunosuppression, facial pain, and a black crusting lesion is invasive fungal sinusitis until proven otherwise, most concerning for mucormycosis. His necrotic nasal lesion and orbital involvement put him in the sick category, so the move is immediate liposomal amphotericin B, antipseudomonal antibiotics if febrile/septic, urgent ENT/ophthalmology evaluation for biopsy and surgical debridement, and ICU-level monitoring if unstable. The correct disposition is admission, likely ICU or step-down depending on vitals and extent, with no delay for culture confirmation.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“58-year-old man with recent chemotherapy presents with one week of fever and worsening left facial pain. He now has a black necrotic crust on the nasal bridge with progressive periorbital swelling and decreased eye opening; he’s immunocompromised and has been getting weaker, but no trauma or rash elsewhere. On exam he’s febrile and ill-appearing with dusky nasal tissue and orbital edema, concerning for invasive fungal sinusitis with possible orbital extension. I’ve started broad antipseudomonal coverage for neutropenic sepsis risk and am initiating liposomal amphotericin B. ENT and ophthalmology are being consulted now for urgent biopsy and surgical evaluation, and I’m admitting him at ICU level given the risk of rapid progression.”
Study Directive
Draw a 3-column table from memory: Candida vs Aspergillus vs Mucorales, with first-line drugs and hallmark clues.
Practice a 30-second script for “febrile neutropenia with necrotic facial lesion.”
Write the liposomal amphotericin dose from memory, then verify against a reference once.
Review when to choose echinocandin vs voriconazole vs amphotericin based on host and anatomy.
Commit to memory the trigger for emergent ENT/ophtho consult: necrosis, orbit, or cranial nerve involvement.
Syphilis is a great imitator with major consequences if missed: neonatal infection, neurosyphilis, ocular disease, and progression through stages if...
A 29-year-old woman sits under fluorescent lights, annoyed by the delay, with a painless sore on her vulva and a faint copper-colored rash on her palms. She says it started as “one little bump” and now she feels fine except for a headache that won’t quit. The lesion isn’t tender, there’s no fever, and she is embarrassed enough to answer in one-word fragments. Her chart hints at a pregnancy test she hasn’t mentioned yet, and the question is what to do before the room turns over.
Before You Read
What lesion/rash combination should make syphilis jump to the top?
When do you treat before confirmatory testing?
Which neurologic or ocular symptoms change the workup immediately?
Why It Matters
Syphilis is a great imitator with major consequences if missed: neonatal infection, neurosyphilis, ocular disease, and progression through stages if untreated. Emergency clinicians need to recognize the patterns, treat early when indicated, and identify who needs spinal fluid or eye evaluation.
When to Think of It
Primary: painless chancre, often with regional adenopathy. Secondary: diffuse rash including palms/soles, mucous patches, condyloma lata, patchy alopecia, systemic symptoms. Early neurosyphilis, ocular syphilis, and otosyphilis can occur at any stage; think of syphilis with unexplained vision change, hearing loss, meningitis-like headache, stroke in a young person, or cranial neuropathies.
Sick or Not Sick
The key fork is simple early syphilis vs neurologic/ocular/otic disease or pregnancy. Neurologic or ocular symptoms require urgent specialty evaluation and treatment escalation; pregnancy requires prompt treatment with penicillin to prevent congenital infection.
The First Fifteen Minutes
If classic primary/secondary/early latent syphilis and follow-up is likely → benzathine penicillin G 2.4 million units IM once, because it reliably treats early infection in one dose.
If late latent syphilis or unknown duration and no neuro/ocular findings → benzathine penicillin G 2.4 million units IM weekly x3 doses, because longer infection needs prolonged exposure.
If penicillin allergy in nonpregnant patient with early syphilis → doxycycline 100 mg PO BID for 14 days (early) or 28 days (late latent), because it is a reasonable alternative when penicillin cannot be used.
If pregnancy, neurosyphilis, ocular syphilis, or confirmed/highly suspected congenital exposure → penicillin desensitization and penicillin therapy, because penicillin is the only proven therapy in pregnancy and the preferred therapy for CNS/eye disease.
If ocular symptoms (vision loss, photophobia, eye pain) → urgent ophthalmology evaluation, because ocular syphilis can threaten vision even with modest systemic findings.
If meningitis, stroke, focal deficits, or altered mental status → LP and neurosyphilis regimen, because CNS disease changes drug choice and duration.
Definitive Care & Disposition
Stage disease with nontreponemal and treponemal tests, but don’t let testing delay treatment when suspicion is high. Admit if neurosyphilis/ocular disease, severe systemic illness, or inability to ensure treatment/follow-up; otherwise treat and arrange public health partner notification and HIV testing. The standard neurosyphilis regimen is aqueous crystalline penicillin G 18–24 million units/day IV, given as 3–4 million units q4h for 10–14 days.
How This One Kills
The dangerous miss is overlooking ocular or neurologic involvement and giving a single IM dose for a disease that actually needs IV therapy. Another common failure is missing syphilis in pregnancy, where delayed treatment can permanently harm the fetus.
The Atypical Presentation
Syphilis often shows up without the “textbook” story. Patients may deny a chancre because it was painless and resolved, secondary disease may present as vague malaise or rash blamed on allergy, and older or immunocompromised patients can have atypical neurologic or ocular complaints. In the ED, the clue is a mismatched constellation: rash on palms/soles, painless ulcer, unexplained neurologic/eye symptoms, or risk factors plus uncertain staging.
Back to Our Patient
Back to our patient: the 29-year-old woman with a painless vulvar sore, palmar rash, and headache has syphilis until proven otherwise, with a need to ask specifically about vision and hearing changes. If her headache is accompanied by ocular symptoms or neuro deficits, she moves into the neurosyphilis/ocular syphilis pathway and needs LP and IV penicillin rather than a single IM dose. If she remains without neuro-ocular findings and is not pregnant, early syphilis treatment with benzathine penicillin G 2.4 million units IM is appropriate, plus testing, HIV evaluation, and follow-up.
Patient Presentation to Attending
“29-year-old woman with a painless vulvar ulcer and new rash on the palms, here for STI evaluation. She denies fever, purulent discharge, or painful vesicles, but reports a persistent headache and no vision changes or hearing loss; pregnancy status is still being checked. Exam shows a non-tender ulcer and diffuse faint palm rash without vesicles or fluctuance, which is concerning for early syphilis. I’m sending treponemal and nontreponemal testing, HIV testing, and I’ll treat presumptively if follow-up is uncertain; if she has any ocular or neurologic symptoms, I’ll escalate to neurosyphilis workup and IV penicillin.”
Study Directive
Memorize the stage-to-treatment map: early, late latent, neurosyphilis, pregnancy.
Practice a focused sexual history that includes partner exposure, lesions, vision, and hearing.
Drill the ocular/neuro red flags that mandate LP or ophthalmology.
Review how to interpret treponemal vs nontreponemal tests and why treatment may start before confirmation.
Key Medications
Benzathine penicillin G: 2.4 million units IM once for early syphilis; 2.4 million units IM weekly x3 for late latent/unknown duration.
Aqueous crystalline penicillin G: 18–24 million units/day IV, typically 3–4 million units IV q4h for 10–14 days for neurosyphilis/ocular syphilis.
Doxycycline: 100 mg PO BID for 14 days (early) or 28 days (late latent) if nonpregnant and penicillin-allergic.
Ceftriaxone: dose varies by syndrome and protocol; use reference if considering for neurosyphilis alternatives.
Pediatric congenital syphilis evaluation/treatment is highly protocolized; consult institutional guidance.
High-Yield Pearls
A painless ulcer plus palm/sole rash is syphilis until proven otherwise.
Vision or hearing symptoms turn a routine STI visit into a neurologic emergency.
In pregnancy, penicillin is not optional; desensitization is often required.
The Mimics
Genital herpes — painful grouped vesicles/ulcers point to HSV; confusing it with syphilis misses the need for staging, partner treatment, and pregnancy-specific management.
Chancroid — painful, ragged ulcers and tender nodes suggest chancroid; treating as syphilis alone can leave the true STI untreated.
Psoriasis or drug rash — symmetric palmar/plantar rash can fool you, but mucous patches and sexual exposure history point to syphilis; missing it delays cure and contact tracing.
Sarcoidosis/other inflammatory eye disease — ocular inflammation without STI consideration can be misleading; missing syphilis risks irreversible visual loss.
Board Question
A 34-year-old man has a painless penile ulcer and a diffuse rash involving the palms and soles. He is afebrile and has no neurologic or ocular symptoms. Which is the best treatment?
ADoxycycline 100 mg PO daily for 7 days
BBenzathine penicillin G 2.4 million units IM once
CAqueous penicillin G 4 million units IV q4h for 10 days
DFluconazole 150 mg PO once
Reveal answer
Correct: B
This is early syphilis, which is treated with a single dose of benzathine penicillin G if there is no neurosyphilis or ocular disease. IV penicillin is reserved for CNS/eye involvement, and doxycycline dosing here is incorrect.
Tick-borne infections can progress quickly to encephalitis, shock, hemolysis, or multi-organ failure, and many are treatable if recognized early. Emergency...
A 46-year-old hiker in a sun-faded ballcap sits flushed and miserable, with a fever, splitting headache, and a rash he noticed only after changing clothes. He smells faintly of sweat and bug spray, and there’s a tiny dark scab in the center of one ankle where he swears “something bit me.” His blood pressure is okay for now, but his platelets are not, and the lab tech has already called twice. The question is whether this is a simple fever after the woods or the start of organ failure.
Before You Read
Which tick-borne illness is treated before the confirmatory test comes back?
What rash pattern or lab clue should make you treat immediately?
When do you add doxycycline even if the diagnosis is not yet certain?
Why It Matters
Tick-borne infections can progress quickly to encephalitis, shock, hemolysis, or multi-organ failure, and many are treatable if recognized early. Emergency care is about pattern recognition, early doxycycline, and not waiting for serologies.
When to Think of It
Think of tick-borne disease with fever plus rash, headache, myalgias, thrombocytopenia, transaminitis, hyponatremia, meningismus, hemolysis, or a known tick bite/exposure. Rocky Mountain spotted fever, ehrlichiosis, anaplasmosis, Lyme disease, babesiosis, tularemia, and relapsing fever are the big ED considerations; geography and season matter.
Sick or Not Sick
The fork is simple suspected tick-borne illness vs severe/systemic disease. Altered mental status, hypotension, respiratory distress, jaundice/hemolysis, bleeding, or inability to tolerate PO = severe disease and admission.
The First Fifteen Minutes
If RMSF, ehrlichiosis, anaplasmosis, or undifferentiated tick-borne febrile illness is plausible → doxycycline 100 mg PO or IV BID now, because delays increase mortality and doxycycline covers the most dangerous treatable pathogens.
If unable to tolerate PO or critically ill → doxycycline 100 mg IV BID, because the same drug needs to get in immediately even when oral absorption is unreliable.
If severe RMSF with shock or organ failure → ICU care, fluids, vasopressors as needed, because treatment failure is often from late recognition and supportive needs.
If babesiosis with hemolytic anemia or parasitemia and systemic illness → atovaquone 750 mg PO BID plus azithromycin 500–1000 mg PO/IV daily, because this combination treats intraerythrocytic protozoa; severe cases may need clindamycin 600 mg IV q6h plus quinine 650 mg PO q8h, but dosing varies and should be checked.
If Lyme disease with erythema migrans but no neuro/cardiac disease → doxycycline 100 mg PO BID, because early localized disease is treated orally.
If meningitis, facial palsy, heart block, or severe headache with tick exposure → broaden evaluation for neurologic Lyme or rickettsial disease, because management and disposition change.
Definitive Care & Disposition
Confirmatory tests are often retrospective; treatment is clinical. Admit severe cases, pregnant patients with systemic illness, hemolysis, organ dysfunction, or inability to ensure follow-up. Consider CBC, CMP, smear for babesiosis, and PCR/serologies as appropriate, but don’t delay doxycycline when RMSF/ehrlichiosis is plausible. Counsel on tick removal, prevention, and return precautions for worsening neuro, pulmonary, or bleeding symptoms.
How This One Kills
The big miss is waiting for the rash to “declare itself” before starting doxycycline. RMSF can kill before the classic rash is obvious, and early labs may be nonspecific.
The Atypical Presentation
Older adults, children, and partially treated patients may not have the classic rash or remembered tick bite. They show up with fever, GI symptoms, headache, confusion, or just abnormal labs—especially thrombocytopenia and transaminitis. If the season and exposure fit, the absence of a “textbook” rash should not stop treatment.
Back to Our Patient
Back to our patient: the 46-year-old hiker with fever, headache, rash, thrombocytopenia, and an ankle eschar-like bite mark needs immediate doxycycline because RMSF/ehrlichiosis are on the table and waiting is dangerous. He is not “watch and wait” if labs are worsening or mental status changes; if he develops hypotension, hypoxia, or confusion, he becomes an admission or ICU patient. If hemolysis or smear findings suggest babesiosis instead, therapy shifts to atovaquone plus azithromycin, but doxycycline is still the urgent bridge when the diagnosis is uncertain.
Patient Presentation to Attending
“46-year-old man after a hiking trip with fever, severe headache, and a new rash, now with thrombocytopenia and mild transaminitis. He remembers a tick bite-like lesion at the ankle but no known bull’s-eye rash; he has no neck stiffness, no focal neuro deficits, and is hemodynamically stable right now. Given the exposure history and lab pattern, I’m most concerned for a rickettsial illness such as RMSF or ehrlichiosis. I’ve given doxycycline 100 mg now and am checking CBC, CMP, and additional testing for babesiosis if hemolysis appears; disposition depends on clinical trajectory, but I’m watching closely for need for admission if he worsens.”
Study Directive
Build a one-page grid of tick-borne disease by syndrome, rash, lab pattern, and first-line therapy.
Practice identifying when babesiosis, not RMSF, is the likely diagnosis.
Memorize the doxycycline dose and the “don’t wait for serology” rule.
Review local pediatric doxycycline guidance for suspected rickettsial disease.
Key Medications
Doxycycline: 100 mg PO or IV BID for suspected RMSF/ehrlichiosis/anaplasmosis/Lyme; pediatric use depends on age and syndrome—consult guidance, but short courses are now commonly used when indicated.
Quinine: 650 mg PO q8h for severe babesiosis; significant variability and toxicity—check reference/protocol.
Ceftriaxone: 2 g IV daily is commonly used for neurologic Lyme/carditis in many protocols; verify local guidance.
Doxycycline pediatric considerations vary by age and indication; use current pediatric guidance rather than older blanket restrictions.
High-Yield Pearls
In tick-borne disease, geography and lab pattern often matter more than the remembered bite.
Thrombocytopenia plus transaminitis after outdoor exposure should trigger doxycycline.
A missing rash does not rule out RMSF; an evolving rash may appear late.
The Mimics
Viral syndrome — diffuse myalgias without thrombocytopenia/transaminitis often misleads; confusing it with RMSF delays doxycycline.
Meningococcemia — petechiae/purpura and shock can resemble severe rickettsial disease; missing meningococcemia delays life-saving broad-spectrum antibiotics.
Drug reaction — rash after new meds can distract from a true tick exposure; mislabeling it as allergy can miss a treatable zoonosis.
STARI/Lyme-like rash — similar annular lesions differ by geography and systemic findings; confusing them may change duration and urgency of therapy.
Board Question
A 7-year-old boy returns from summer camp with fever, headache, vomiting, and a petechial rash on the wrists and ankles. Platelets are low and AST/ALT are mildly elevated. What is the best next treatment?
AAmoxicillin-clavulanate
BDoxycycline
CAcyclovir
DOseltamivir
Reveal answer
Correct: B
This presentation is highly concerning for Rocky Mountain spotted fever, which should be treated immediately with doxycycline. Waiting for confirmatory testing increases the risk of severe complications and death.
Febrile infants and children can deteriorate rapidly, and missed serious bacterial infection is a high-stakes ED failure. The emergency task is to identify...
A 19-day-old infant arrives bundled in a fleece blanket, sleeping too deeply for a baby that age, with a faintly mottled chest and a temperature taken three different ways. The mother says the baby fed less overnight and has been “hard to wake,” but there’s no cough, no vomiting, no obvious source. The diaper is wet, the fontanel is flat, and the room feels too quiet. The challenge is that the infant still looks almost normal.
Before You Read
Which febrile child is automatically high risk, even if they look well?
What must be done before discharge in a young infant with no clear source?
Which findings push this from “fever” to invasive bacterial disease?
Why It Matters
Febrile infants and children can deteriorate rapidly, and missed serious bacterial infection is a high-stakes ED failure. The emergency task is to identify age-based risk, screen for sepsis/meningitis/UTI/bacteremia, and decide who needs immediate antibiotics and admission.
When to Think of It
Any infant under 60 days with fever is high risk; under 28 days is especially concerning even if the exam is bland. Serious bacterial infection should be considered with fever plus ill appearance, poor feeding, lethargy, irritability, apnea, respiratory distress, petechiae/purpura, neck stiffness, focal infection, dehydration, or abnormal perfusion. UTI is the most common SBI in many febrile infants, but bacteremia, meningitis, and pneumonia must be screened for based on age and appearance.
Sick or Not Sick
The single fork is age and appearance: toxic/ill-appearing vs well-appearing, with age under 28 days the highest-risk group. Ill appearance or young age usually means full sepsis evaluation and parenteral antibiotics; older well-appearing infants may qualify for structured low-risk pathways only if all criteria are met.
The First Fifteen Minutes
If ill-appearing infant or neonate with fever → full sepsis evaluation and immediate IV antibiotics after cultures: ampicillin 50 mg/kg IV plus gentamicin 4–5 mg/kg IV, or ampicillin 50 mg/kg IV plus cefotaxime 50 mg/kg IV, because coverage must include GBS, Listeria, and gram-negative organisms.
If neonatal meningitis is a concern → ampicillin 50 mg/kg IV plus cefotaxime 50 mg/kg IV, because cefotaxime penetrates CSF better than gentamicin.
If age 29–60 days and well appearing but not clearly low risk → obtain blood/urine studies and consider ceftriaxone 50 mg/kg IV/IM once, because this can bridge until culture results and follow-up.
If HSV is in the differential in a sick neonate (vesicles, seizures, transaminitis, CSF pleocytosis, maternal HSV, ill-appearing without source) → acyclovir 20 mg/kg IV q8h, because missing neonatal HSV is catastrophic.
If shock or poor perfusion → isotonic fluid bolus 10–20 mL/kg IV, because restoring intravascular volume buys time while cultures and antibiotics are obtained.
If febrile child older than 3 months with clear source and well appearance → targeted workup, not blanket antibiotics, because over-treatment can obscure diagnosis and create harm.
Definitive Care & Disposition
Obtain age-appropriate workup: CBC, blood culture, urinalysis/urine culture, inflammatory markers per pathway, and lumbar puncture when indicated. Admit all neonates with fever, most ill-appearing children, and any child with meningitis, bacteremia, or unreliable follow-up. Discharge only low-risk, well-appearing older infants/children when a validated pathway is met and close follow-up is guaranteed.
How This One Kills
The classic failure is sending home the “well-appearing” neonate with fever because the exam is reassuring. Serious bacterial infection in this age group often starts subtle and becomes devastating after the child leaves.
The Atypical Presentation
Young infants often look deceptively well, and the fever may be reported at home rather than present in the ED. Partial antipyretic use, recent antibiotics, or a normal-appearing skin exam can falsely reassure. The catch is age plus subtle behavioral change: poor feeding, lethargy, or “not acting right” in a baby under 60 days is enough to keep SBI high on the list.
Back to Our Patient
Back to our patient: the 19-day-old with fever, poor feeding, and lethargy is a neonatal fever until proven otherwise, even without a source or obvious distress. Because she is under 28 days, she is in the highest-risk group and needs cultures, full sepsis evaluation, and immediate IV antibiotics after workup, with ampicillin plus gentamicin or cefotaxime; if HSV clues emerge, acyclovir is added. The appropriate disposition is admission, typically to the hospital or NICU depending on exam and stability, not discharge.
Patient Presentation to Attending
“19-day-old infant with fever and decreased feeding, brought in because mom says the baby is harder to wake and seems a little mottled. There’s no cough, vomiting, rash, or focal source, and the fontanel is flat, but this is a neonate under 28 days so serious bacterial infection remains high risk despite a relatively bland exam. I’m concerned about neonatal sepsis and possibly meningitis; I’ve obtained cultures and am planning full sepsis workup with immediate IV ampicillin plus gentamicin or cefotaxime per protocol. If any HSV features show up, I’ll add acyclovir, and I do not think this infant is safe for discharge.”
Study Directive
Memorize the age cutoffs: <28 days, 29–60 days, older infant.
Practice a neonatal fever algorithm from memory, including when to add HSV coverage.
Drill weight-based neonatal antibiotic doses and the “after cultures, before delay” rule.
Review discharge criteria for low-risk older infants and what makes them fail low-risk pathways.
Mechanism Pearl of the Day: The day’s common thread is time-dependent pathogen control before irreversible host damage: angioinvasive fungi thrombose vessels, rickettsiae injure endothelium, spirochetes hide in neurologic/ocular sanctuaries, and neonatal bacteria overwhelm immature immunity. In each case, the ED win is to recognize the host-risk pattern and start the right drug before the organism’s mechanism outruns the exam.
Key Medications
Ampicillin: 50 mg/kg IV per dose; neonatal frequency depends on age and weight, verify protocol.
Gentamicin: 4–5 mg/kg IV once daily or per neonatal schedule; check levels and local dosing.
Cefotaxime: 50 mg/kg IV per dose; frequency depends on age and syndrome, verify protocol.
Ceftriaxone: 50 mg/kg IV/IM once; avoid in significant neonatal hyperbilirubinemia and with calcium-containing fluids.
Acyclovir: 20 mg/kg IV q8h for suspected neonatal HSV.
Normal saline / Lactated Ringer’s: 10–20 mL/kg IV bolus for shock or poor perfusion.
Pediatric dosing is highly age-dependent; confirm all neonatal antibiotic regimens with institutional guidance.
High-Yield Pearls
In febrile infants, age is a stronger risk signal than how cute or consolable they look.
Poor feeding and lethargy are sepsis until proven otherwise in neonates.
Never let a normal fontanel or nonfocal exam override age-based risk.
The Mimics
Viral bronchiolitis or URI — cough/congestion can coexist, but age-based fever risk remains; confusing them with SBI misses bacteremia or meningitis.
Dehydration/poor feeding alone — this can be the first sign of sepsis; attributing it to a feeding problem delays antibiotics.
Febrile seizure — the seizure may be brief and self-limited, but fever source still needs age-based evaluation.
Innocent irritability/colic — a quiet, poorly feeding infant may actually be septic; missing the trajectory is dangerous.
Board Question
A 17-day-old neonate has a rectal temperature of 38.3°C (100.9°F) and otherwise appears well in the ED. Which is the best disposition?
ADischarge with pediatric follow-up tomorrow
BFull sepsis evaluation and admission
COral amoxicillin and outpatient urine culture
DNo workup because the infant looks well
Reveal answer
Correct: B
Any febrile infant under 28 days is high risk and requires full sepsis evaluation and admission, even if they appear well. The exam can be deceptively normal early in serious bacterial infection.
A quick test of recall from prior editions. Commit to an answer before you check.
From yesterday's edition
A 59-year-old man presents with diaphoresis and epigastric pressure. The ECG shows ST elevation in II, III, and aVF with reciprocal ST depression in I and aVL. What’s the diagnosis, and the first move?
Check your answer
Inferior STEMI. Activate STEMI pathway, give antiplatelet/anticoagulation per local protocol, obtain right-sided/posterior leads when indicated, avoid nitrates if RV infarct or hypotension is suspected, and involve cardiology immediately.
From the June 15 edition
Today, three days ago: Intravenous Lipid Emulsion. What’s the adult ED dose, and the contraindication you’d most regret missing?
Check your answer
20% lipid: 1.5 mL/kg IV bolus over 2–3 min, then 0.25 mL/kg/min infusion. Repeat bolus/increase infusion for persistent instability; observe maximum cumulative dose per protocol. Relative only in arrest/refractory shock.
From the June 8 edition
A 56-year-old man with known pulmonary arterial hypertension becomes acutely hypotensive and dyspneic after intubation for respiratory failure. Which physiologic change most likely contributed to his decompensation?
AIncreased left ventricular preload
BDecreased pulmonary vascular resistance
CReduced right ventricular preload and increased intrathoracic pressure
DImproved right ventricular contractility
Reveal answer
Correct · C
Positive-pressure ventilation increases intrathoracic pressure, which reduces venous return and right ventricular preload, and can also worsen RV afterload in patients with PH. These patients may decompensate rapidly after induction or initiation of mechanical ventilation.
Journal Watch
From the FOAMed wire
Notable posts and reviews from the last week, ranked by relevance to today’s lead and source trust.
New Mexico recently passed landmark medical malpractice reform due largely to sustained advocacy by New Mexico ACEP.... The post New Mexico ACEP Scores Win for Malpractice Reform appeared first on ACEP Now .
On the heels of a letter from ACEP and EMRA, the Accreditation Council for Graduate Medical Education (ACGME)... The post ACGME Will Seek More Input on Proposed Changes to EM Residency Programs appeared first on ACEP Now .
In this episode, Sam Ashoo, MD and Dr. T.R. Eckler, MD discuss the April 2026 Emergency Medicine Practice article, Wide Complex Tachycardia in the Emergency Department: An Updated Approach to Diagnosis and Management . Introduction – 0:11 Article Overview – 2:02 Top 5 Bedside Steps – 7:54 Sodium Channel Blockade – 9:26 Hyperkalemia – 11:53 SVT with...
Part 2 of Shock Hemodynamic Physio brings Phil and Rory to discuss the 4 Interface Model EMCrit Project by Scott Weingart, MD FCCM .
Pharmacology Corner
Two drugs for the shift
One antimicrobial and one other ED workhorse — selected daily, with sources and last-reviewed dates so every dose is cross-checkable.
Antimicrobial of the Day
Valacyclovir
Nucleoside analog antiviral (acyclovir prodrug)
Indication
Herpes zoster, genital and orolabial HSV (initial and recurrent episodes), HSV suppression, and varicella.
What’s your dose? — reveal dosing & cautions
ED Dose
Herpes zoster: 1 g PO TID x7 days. Genital HSV initial: 1 g PO BID x7–10 days; recurrent: 500 mg PO BID x3 days. Orolabial (cold sore): 2 g PO BID x1 day.
Renal Adjustment
Dose-adjust when CrCl < 50 mL/min; elderly and renally impaired patients are at higher risk of neurotoxicity.
Contraindications
Hypersensitivity to valacyclovir or acyclovir.
Interactions
Additive nephrotoxicity with other nephrotoxins; probenecid and cimetidine increase levels.
Monitoring
Renal function and hydration; neurologic status (confusion, hallucinations, especially in renal impairment).
ED Pearl
A prodrug of acyclovir with far better oral bioavailability and BID–TID dosing (vs 5×/day acyclovir). Start zoster therapy within 72 h of rash onset; in renal impairment reduce the dose and ensure hydration to avoid neurotoxicity and crystal nephropathy.
Vasodilatory hypotension with tachyarrhythmia concerns, procedural/peri-intubation hypotension, and selected anesthesia-related hypotension; not preferred for most septic shock.
What’s your dose? — reveal dosing & cautions
ED Dose
Infusion: 0.1–0.5 mcg/kg/min, titrate to MAP. Push-dose: commonly 50–200 mcg IV aliquots using institution-approved premixed concentration.
Renal Adjustment
No renal adjustment; titrate to effect.
Contraindications
Severe hypertension, ventricular tachycardia. Relative caution in cardiogenic shock/poor cardiac output due to afterload increase.
Interactions
MAOIs/TCAs may potentiate; beta-blockers may worsen reflex bradycardia; oxytocics may intensify hypertension.
ED Pearl
Phenylephrine may make the number look better while worsening cardiac output; in shock, ask whether the patient needs squeeze, heart rate support, or actual forward flow.
Regular narrow-complex tachycardia without clear P waves is usually AVNRT or AVRT at the bedside — stability determines the first move.
The Tracing
A 28-year-old patient has sudden-onset palpitations while at rest. The ECG shows a regular narrow-complex tachycardia at 196 bpm. P waves are not clearly visible, and the QRS complexes are narrow and identical. The patient is anxious but normotensive.
P waves absent, retrograde, buried in QRS, or visible just after QRS depending on mechanism
QRS usually narrow unless aberrancy or pre-existing bundle branch block is present
Onset and termination are often abrupt
Includes AVNRT, orthodromic AVRT, atrial tachycardia, and other supraventricular mechanisms
Pearls
Modified Valsalva is a real treatment, not a placebo, and should be done correctly before medication when stable.
Adenosine is diagnostic and therapeutic for AV-node-dependent SVT, but warn the patient before giving it.
Capture a 12-lead before and after conversion if possible; baseline delta waves change the future plan.
Pitfalls
Do not use adenosine casually in irregular wide-complex tachycardia.
Do not miss sinus tachycardia from shock, sepsis, PE, or withdrawal; sinus tach usually has visible P waves and a clinical driver.
Do not discharge recurrent SVT without considering WPW, triggers, and follow-up.
At the Bedside
If unstable, synchronized cardioversion. If stable regular narrow SVT, use modified Valsalva then adenosine per protocol, obtain post-conversion ECG, and plan follow-up/disposition based on recurrence and risk.
For educational use only. Verify ECG interpretation against the LITFL entry and your institution’s practice before clinical decision-making.
Case of the Day
From the lead · Critical Fungal Infection
Self-Examination
Test Your Understanding
A 62-year-old man with poorly controlled diabetes presents with fever, unilateral facial pain, nasal congestion, and a black eschar on the hard palate. He is hypotensive and confused. Which is the best next step?
AIntranasal oxymetazoline and outpatient ENT follow-up
BIV ceftriaxone and observe for clinical improvement
CIV liposomal amphotericin B and urgent surgical consultation
DOral fluconazole and discharge
Reveal answer
Correct answer · C
This is classic rhino-orbital-cerebral mucormycosis until proven otherwise. The key is immediate amphotericin plus urgent debridement; delay for imaging or cultures increases mortality.
Study Pace4 topics today; 104 remaining; Day 17 of 43Deadline · June 1, 2026