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Corneal Trauma or Infection Common Watery or purulent Usually blurred Moderate to severe Mainly circumcorneal Clarity change related to cause Normal Normal Normal Organisms found only in corneal infection

Extremely common Moderate to copious No effect on vision Mild Diffuse; more toward fornices Clear Normal Normal Normal Causative organisms

sequelae Diagnosis can be rapidly confirmed by immunologic tests or polymerase chain reaction on conjunctival samples Treatment is with oral tetracycline or erythromycin, 500 mg four times a day, or doxycycline, 100 mg twice a day, for 1 2 weeks Single-dose therapy with azithromycin, 1 g, may also be effective Before treatment, all cases should be assessed for genital tract infection so that management can be adjusted accordingly, and other venereal diseases sought

Miller KE Diagnosis and treatment of Chlamydia trachomatis infection Am Fam Physician 2006 Apr 15;73(8):1411 6 [PMID: 16669564]

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niae), Haemophilus species, Pseudomonas, and Moraxella All may produce a copious purulent discharge There is no blurring of vision and only mild discomfort In severe cases, examination of stained conjunctival scrapings and cultures is recommended The disease is usually self-limited, lasting about 10 14 days if untreated Topical sulfonamide (eg, sulfacetamide, 10% ophthalmic solution or ointment three times a day) will usually clear the infection in 2 3 days Povidoneiodine may also be effective The use of topical fluoroquinolones is rarely justified for treatment of a generally selflimiting, benign infection

Sheikh A et al Antibiotics versus placebo for acute bacterial conjunctivitis Cochrane Database Syst Rev 2006 Apr 19;(2): CD001211 [PMID: 16625540]

One of the most common causes of viral conjunctivitis is adenovirus type 3 Conjunctivitis due to this agent is usually associated with pharyngitis, fever, malaise, and preauricular adenopathy (pharyngoconjunctival fever) Locally, the palpebral conjunctiva is red, and there is a copious watery discharge and scanty exudate Children are more often affected than adults, and contaminated swimming pools are sometimes the source of infection The disease usually lasts 10 days Epidemic keratoconjunctivitis is caused by adenovirus types 8, 19, 29, and 37 It is more likely to be complicated by visual loss due to corneal subepithelial infiltrates The disease lasts at least 2 weeks Topical sulfonamides prevent secondary bacterial infection and cold compresses reduce the discomfort of the associated lid edema

FIGURE 10-14

The eosinophil count may be high Hyponatremia or hyperkalemia (or both) are usually present Hypoglycemia is frequent Hypercalcemia may be present Blood, sputum, or urine culture may be positive if bacterial infection is the precipitating cause of the crisis The diagnosis is made by a simplified cosyntropin stimulation test, which is performed as follows: (1) Synthetic ACTH1 24 (cosyntropin), 025 mg, is given parenterally (2) Serum is obtained for cortisol between 30 and 60 minutes after cosyntropin is administered Normally, serum cortisol rises to at least 20 mcg/dL For patients receiving corticosteroid treatment, hydrocortisone must not be given for at least 8 hours before the test Other corticosteroids (eg, prednisone, dexamethasone) do not interfere with specific assays for cortisol Plasma ACTH is markedly elevated if the patient has primary adrenal disease (generally > 200 pg/mL)

Rapid treatment will usually be life-saving However, acute adrenal insufficiency is frequently unrecognized and untreated since its manifestations mimic more common conditions; lack of treatment leads to shock that is unresponsive to volume replacement and vasopressors, resulting in death

Hamrahian AH et al Measurements of serum free cortisol in critically ill patients N Engl J Med 2004 Apr 15;350(16): 1629 38 [PMID: 15084695] Jahangir-Hekmat M et al Adrenal insufficiency attributable to adrenal hemorrhage: long-term follow-up with reference to glucocorticoid and mineralocorticoid function and replacement Endocr Pract 2004 Jan Feb;10(1):55 61 [PMID: 15251623]

Acute adrenal insufficiency must be distinguished from other causes of shock (eg, septic, hemorrhagic, cardiogenic) Hyperkalemia is also seen with gastrointestinal bleeding, rhabdomyolysis, hyperkalemic paralysis, and certain drugs (eg, ACE inhibitors, spironolactone) Hyponatremia is seen in many

CHRONIC ADRENOCORTICAL INSUFFICIENCY (ADDISON S DISEASE)

Weakness, easy fatigability, anorexia, weight loss; nausea and vomiting, diarrhea; abdominal pain, muscle and joint pains; amenorrhea Sparse axillary hair; increased skin pigmentation, especially of creases, pressure areas, and nipples Hypotension, small heart Serum sodium may be low; potassium, calcium, and BUN may be elevated; neutropenia, mild anemia, eosinophilia, and relative lymphocytosis may be present Plasma cortisol levels are low or fail to rise after administration of corticotropin Plasma ACTH level is elevated

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