COW Week 15

39yM presents with left facial droop x 2days. No other neurologic symptoms. Given forehead muscle involvement, hyperacusis, you diagnose him with Bell's Palsy. What do you do now?

A) Valacyclovir x 7 days

B) Prednisone x 10 days

C) Prednsione and Valacyclovir

D) Observation  

 Answer: B (C is also acceptable)

Up to 30% of patients with Bell's Palsy fail to recover facial function completely. The disease is common, with an annual incidence of 20 per 100,000 leading to thousands of patients per year with facial weakness. In the updated guidelines from the American Academy of Neurology, oral steroids are recommended for new-onset Bell's palsy to improve recovery of facial function. In these guidelines, 9 studies were identified comparing steroids and antivirals to placebo for Bell's Palsy. Regarding oral steroids, 2 class 1 studies comparing oral prednisolone to placebo for 10 days showed a significant improvement in complete facial recovery translating to a Number Needed to Treat of 6-8 people to achieve one complete recovery.  Regarding antivirals, there was no evidence of any benefit however, the authors conclude that the statistical power was insufficient to exclude a small benefit or harm and some believe that antivirals carry an additional benefit when added to steroids. The academy says that antivirals may be offered in addition to steroids, but patients should be counseled that the benefit is unknown and likely modest at best. 

In Journal Watch Neurology, Robert T. Naismith comments: "The side-effect profile for oral glucocorticoids is relatively favorable, and a 10-day course can be recommended within 3 days after facial-weakness onset. If the patient is evaluated for treatment after 3 days, the benefit may be smaller, and treatment would be up to the judgment of the physician and patient."

Lastly, remember to consider other etiologies such as Lyme, VZV, HSV, rarely HIV, Sjorgren's, Sarcoid and others as some of these do require alternative treatments.

 American Academy of Neurology Updated Guidelines on Bell Palsy

COW Week 14

34 yo F presents for WH appt. Feels well, reports mild non-purulent vaginal discharge x2 months. Monogamous x4 years, no hx of STI. Speculum exam normal, wet mount/koh prep negative. Pap returns normal except rare trichomonas. What next?

1. Intravaginal metronidazole gel (0.75%) once daily for five days
2. Metronidazole 2g po xi
3. Metronidazole 500mg po BID x7d and treat partner
4. New specimen for Fungal and T. vaginalis Cultures -Correct Answer



This is a healthy patient with questionable symptoms (her discharge may also be physiologic).  She is not in a high risk group, and trichmononas, though a common disease, is an unlikely cause in this patient and is a surprising finding.  The most common vaginal discharges are BV, Trich and Candida.  Of the "bedside" tests, the Wet Mount has the best sensitivity (clue cells:sensitivity 98.2%, specificity 94.3%, positive predictive value 89.9%, negative predictive value 99.0%).  The Whiff Test is also relatively sensitive. BV is thus ruled out by the the findings.  Of note Intravaingal Metronidazole is a treatment only for BV, not TV.

KOH prep is not particularly sensitive 60% for vulvovaginal candidasisis (a more likely Dx than Trich in this patient).  If symptoms persist, it may be reasonable to send for gram stain/fungal culture in this patient to clarify the diagnosis. Also fungal culture is indicated if patient has failed Rx for candida to look for non-abicans species.

Wet mount is not particularly sensitive for T. vaginalis (40–70%), especially if there is time lag in sample transport.  Trich is likely under diagnosed as a result, and further investigation is warranted, especially in patients treated for Candida or BV (without partner treatment-as males are almost always asymptomatic). The wet mount does have good specificity for Trich.  Patients with history of STIs should be investigated for T. vaginalis (along with CT/GC) if they have any symptoms of discharge. Any patient that is diagnosed with T. Vaginalis should have partner treatment as well to reduce risk of re-infection, and barrier methods should be used until treatment is complete.

However, in this case we have the opposite situation. We doubt the diagnosis of TV as it did not show up on bedside tests and the patient is not high risk.  The specificity of cytology for trich is such that in an endemic area or high risk population, treatment can be based upon a positive result, but not in low risk/low endemic area. In this case, it's reasonable for us to use a more sensitive and specific test for trichomonas: either culture or PCR to confirm diagnosis. In addition, fungal culture would help rule out candidaisis. 

 Sherrard J, Donders G, White D, Jensen JS; European IUSTI. European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011. Int J STD AIDS. 2011 Aug;22(8):421-9.