25 Feb - Fever and Rash

     Fever and rash in an otherwise healthy male patient with pneumonia.  When working up fever and rash, "Its probably a virus" will be correct much of the time, but there are some never miss life threatening diagnoses to remember.  Unfortunately, the differential diagnosis of fever and rash is only slightly less broad than that of fever alone.  Of all the rashes, petechial / purpuric rash with fever is the most ominous.  Think meningococcemia, RMSF, endocarditis, and fulminant gram negative sepsis.  Ask about the spleen!  I think I will make this article from ID Clinics of North America (Vol 10:1, 1996) required reading for the ID rotation.  It gives a few ways to lump the diagnoses by appearance and determine the treatable, untreatable, and non-infectious possibilities.
     In this patient, the prominent maculopapular rash sparing the palms and soles in conjunction with pneumonia suggest mycoplasma as a diagnosis.  Though generally benign, mycoplasma infections can be severe and even fatal, especially if encephalitis, erythema multiforme, aplastic anemia, or DIC occurs.  This article by Schalock in International Journal of Dermatology 2009,48, 673–681 is a great review of mycoplasma infections covering all the systemic manifestations and focusing on the dermatologic findings.  Up to 1/3 of mycoplasma cases are complicated by an exanthematous eruption according to their review. 
     Finally, when working up a patient with suspected acute retroviral syndrome (fever, rash, sore throat, adenopathy), the plasma viral load is the test of choice.  p24 antigen testing used to be the correct answer, but viral load testing is now preferred.  Low titer viral loads (1000 or less) probably represent false positive tests in this setting.  You can expect a Step 3 / ABIM question on this topic.

24 Feb - Syncope, MI, and LBBB

     Todays case was a patient with a significant underlying seizure history (poorly controlled) who now presents with several episodes of loss of consciousness not associated with convulsions.  Echocardiography revealed a rare congenital malformation - cor triatriatum.  This was likely unrelated to the syncopal event.  It is condition where atrium is divided into two chambers by a septum, which can produce symptoms the functional equivalent of mitral stenosis.
     A brief case discussion focused on patients with chest pain and left bundle branch block.  Symptoms suggestive of cardiac ischemia with a new or unknown duration LBBB should be managed as ST elevation MIs.  In patients with old LBBB and chest pain, some features suggest the presence of MI:  1mm concordant ST elevation, 5mm discordant ST elevation, or 1mm ST depression in leads V1, V2, or V3.  This data came from a substudy of the landmark GUSTO trial that established the usefulness of TPA for treatment of acute MI.  You can expect a question about MI in setting of LBBB on boards.

23 Feb - In the News

High profile stories about aspirin and rosiglitazone sure to stimulate conversations with your patients.  Be sure to calculate a Framingham risk score to help counsel patients about the risk / benefit of daily aspirin.   Based on the above story, those with higher Framingham risk scores may not be good candidates for rosiglitazone until the heart disease risk issue is resolved.

19 Feb - Progressive Multifocal Leukoencephalopathy

     An elderly male with a long history of HIV disease presents with a rapidly progressing dementing illness associated with visaul loss.  His MRI revealed extensive disease predominantly in the white matter but also involving gray matter.  The differential of CNS lesions in AIDS patients is broad, but most cases are attributable to lymphoma, toxoplasmosis, PML, cryptococcus, and rarely (in the US) TB.  In this case CSF was remarkable for high protein and 2 WBCs.  This is a typical bland CSF appearance for PML.  PCR for JC virus was positive.
     PML is a rapidly progressive demyelinating disease caused by the JC polyoma virus that is usually fatal.  Most cases are associated with AIDS, however cases have been reported in patients recieving natalizumab for treatment of MS.  There is no treatment (other than retroviral drugs to treat HIV disease).
     The other major human disease caused a polyomavirus is the BK virus induced nephropathy in kidney transplant patients. 
     Remember the most up to date management strategy for differentiating toxoplasmosis from lymphoma is to perform Thallium 201 SPECT with early brain biopsy for lesions suspicious for lymphoma.  The old strategy of treat for toxo for 2 weeks and biopsy those that do not improve is not as favored given the peformance of SPECT.

18 Feb - glands run amok

     Todays discussion of a patient admitted with atrial fibrillation with RVR brought up several important points.  Will not dwell on A-fib here as it was discussed extensively last week.  One is proper dosing and adjustment of thryoid hormone supplements.  Start low and go slow, especially in the elderly and patients with cardiac disease.  Also remind patients to take their mediciation in the AM on an empty stomach.  Erratic dosing produces erratic results. 
     Interpreting results of parathyroid hormone testing can be a challenge.  Values in the "normal" range represent hyperparathyroidism if the calcium is elevated.  Don't forget to evaluate for vitamin D deficiency as a cause of secondary hyperparathyroidism, but in those cases serum calcium should be low, not high.  This July 11, 1999 Lancet review covers all you every wanted to know about hyperparathyroidism. 
     Pearl - hypothyroid patients often have elevated lipids, and thyroid hormone supplementation reduces LDL cholesterol but has no effect on HDL, triglycerides, apo AI or Lp(a).  Expect to see something about this on boards.  See here and here for more info.

17 Feb - cryptococcal meningitis in an immunocompetent patient

     Todays case was a young otherwise healthy male with chronic meningitis.  Cerebrospinal fluid analysis revealed abundant mononuclear cells, high protein, and low glucose.  In the developing world this strongly suggests TB.  In the US, most likely it is cryptococcus or histoplasmosis.  There are several other causes of the chronic meningitis syndrome, nicely summarized in this Nov 1999 Neurological Clinics article available here at MD Consult.  Though often associated with HIV/AIDS, cryptococcal disease occurs in immunocompetent patients.  There is an emerging outbreak of a novel pathogen, Cryptococcus gattii, in the Pacific Northwest, especially Vancouver Island - so watch for it in travelers returning from the Olympics.  This has caused significant morbidity and mortality in both immunosuppressed and immunocompetent patients.  Recently updated treatment guidelines for cryptococcal disease can be found here.  Traditional teaching is that all patients with cryptococcus isolated from sputum require lumbar puncture to exclude cryptococcal meningitis.  The recent guidelines indicate that select immunocompetent patients with negative serum cryptococcal antigen titers and no signs of meningitis can be managed without lumbar puncture.  All immunosuppressed patients require LP, whether they have meningitis symptoms or not.
     On an related note, this recent JAMA article on performance and interpretation of lumbar puncture lists the "normal" opening pressure as 6 - 14 mm Hg or 6 - 18 cm H2O. 
 

16 Feb - CPC on Pulmonary Embolism

     Code in the middle of the night, rhtyhm other than v-tach (especially PEA) think PE.  Frequently overlooked, often preventable, PE remains a leading killer of hospitalized patients.  It is missed much less often today than in the past, some speculate due to widely available CT angiography and increased clinical awareness of this condition.  Here is a recent Mayo Clinic study that found PE to an uncommon cause of Type I autopsy findings (Type I = diagnosis missed pre-mortem that would have altered outcome if treated).
     The role of using thrombolytics to treat suspected PE in the setting of a code is controversial.  The British Thoracic Society recommends its use for massive PE with hemodynamic collapse.  In these cases your diagnosis has to be clinical.  Patients stable enough to go to the scanner are too stable to use thrombolytics.  The dose, if you so choose, is 50mg alteplase given as a bolus.  In a small randomized trial of heparin vs lytics for massive PE, all 4 patients given heparin died and all given lytics lived.  This is the extent of the "high quality" data for this condition.  The way I see it, the outcome of PEA code is so bad that if PE is high on the differential push the lytics, because you might help and you can't really make things much worse at that point.
    For further reading on management and prevention of thrombosis in hospitalized patients, review the Venous Thromboembolism Prophylasis module on the Johns Hopkins hospitalist curriculum.  Requires login, but it is free.  Also linked on the links section of this blog.

11 Feb Aortic Stenosis

Why internists love this topic so much is beyond me.  There is essentially no medical management that improves the condition.  We just have to sit around long enough for the patient to get sick enough to refer to a surgeon.  When are they sick enough?  This slide from the AHA Valvular Heart Disease guidelines is a nice flowchart.  Essentially any patient with severe AS with symptoms or LV systolic dysfunction (EF<50) should be referred for valve surgery.

Also remember the association of colonic arterivenous malformations and AS, also known as Heyde Syndrome.  In the case presented today, symptomatic gastrointestinal hemorrhage complicated management and necessitated placement of a tissue rather than mechanical valve so as to avoid anticoagulation. 

10 Feb Cocaine Induced Myocardial Ischemia

Cocaine and heart disease - not a good combo.  Several mechanisms for cardiac ischemia - increased workload from high SVR, coronoray vasospasm, and long term toxic cardiomyopathy.  For more reading see this article via Medscape:

Cocaine Cardiomyopathy

Key point - beta blockers, particularly without concomitant alpha blockers, are generally a bad idea in chronic cocaine users.

Pearl - ST depressions always represent pathology, ST elevations may be normal, and are seen in several conditions other than acute myocardial infarction.  Thease are summarized nicely in this NEJM article.  90% of young males will have upsloping ST elevations in lead V2 (data from old USAF study - hooah!).  Read the article and impress your attending next time you do cards!

NEJM ST Elevation Article

9 Feb Acute Pancreatitis Grand Rounds

Dr Rollhouser was kind enough to share his talk from this mornings grand rounds on acute pancreatitis:

Acute Pancreatitis Talk

8 Feb - Acute Kidney Injury

Fanconi syndrome:  proximal tubular dysfunction with resultant type2 RTA associated with renal loss of glucose, amino acids, magnesium, and potassium.  Associated with use of tenofovir, codofovir, and tetracycline.  Think of this when urine dipstick is positive  for glucose but the serum glucose is <150.

Remember the three most common causes of acute kidney injury in hospitalized patinets:  volume depletion, medications, and radiocontrast administration.  A nice study covering this subject was published in the American Journal of Kidney Diseases 2002, Vol 39: 930-936.  Full text available via MD Consult at:

AJKD Vol 39:930 - 936

Also, remember to use the RIFLE criteria for staging AKI patients.  Risk = Cr increased 1.5X, Injury = 2X, and Failure = 3X.  L = persistent total loss of kidney function > 4 weeks, and E = ESRD.  This has been validated as a prognostic tool in patients who develope AKI.  A review of the literature from 2007 is linked below:

Kidney International, 2008 73:538

5 Feb - CHF/Afib

Todays discussion centered on management of CHF/A-fib management issues.

One discussion concerned the CAFE-II (NEJM Jun 19, 2008) study .  Despite the fact that atrial fibrillation is poorly tolerated in heart failure patients, working to restore sinus rhythm did not improve outcomes compared to rate control alone. 

http://content.nejm.org/cgi/content/abstract/358/25/2667

A Lancet article 11 Aug 2007 published results of the BAFTA trial analyzing the use of warfarin in elderly patients with atrial fibrillation.  20% of study subjects were >85 years old, and in all subsets the benefit appeared to outweigh the harm.  You can get full text Lancet access through science direct in the hopsital.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4PCSC5S-12&_user=2763990&_coverDate=08%2F17%2F2007&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000058752&_version=1&_urlVersion=0&_userid=2763990&md5=b766d43281583dd9944244e897cf5559

Also, be sure to remember the CHADS-2 score:
CHF, Age >75, HTN, and diabetes 1 point each, with 2 points for prior stroke or TIA.  3 points is a roughly 6% stroke rate per year and goes up with each additional risk factor.  Handy on-line tool linked below.

http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk

4 Feb Cirrhosis / Ascites / Encephalopathy

Several issues were discussed regarding the management strategies for hepatic encephalopathy as well as the optimum evaluation of patietns for suspected SBP. 

A recent Medical Clinics of North America (July 2009) has an excellent review of hepatic encephalopath and treatment and is avaialbale through the MD Consult core collection:
http://www.mdconsult.com/das/article/body/182021411-2/jorg=journal&source=&sp=22299341&sid=0/N/704543/s0025712509000406.pdf?issn=0025-7125
The article covers pathophysiology, staging, and reviews the literature on effective therapies.  Interestingly, testing for zinc deficiency and supplementing those with low levels seems to improve cognitive function according to a few studies referenced in that article.

When to perform paracentesis to evaluate for SBP is addressed in the following article from JAMA (March 12, 2008 issue).  That article states a 27% rate of infection in cirrhotic patients with ascites admitted to the hospital for complications of cirrhosis.  Fever is often absent, but when present paracentesis should always be part of the workup.  Paracentesis should also be considered in any cirrhotic presenting with nausea, abdominal pain, or altered mental status.  This article summarizes the data regarding interpretation of results and treatment options for SBP.  Consider primary prophylaxis for SBP in cirrhotics with low-protein ascites, and secondary prophylaxis in anyone with previous SBP.  This is the article I will use for sim center teaching when the model is available later this year, so know it and know it well.

http://jama.ama-assn.org/cgi/reprint/299/10/1166

3 Feb Anticoag / Dabigatran

Discussion today regarding reversal of over-anticoagulation with warfarin. Link to recent Annals trial attached - essentially showed that low-dose vitamin K did not improve clinical outcomes in patients with elevated INR due to warfarin overdosage.

http://www.annals.org/content/150/5/293.full

Also - here is the link to the NEJM article on dabigatran. This oral direct thrombin inhibitor was equivalent to warfarin in preventing stroke in patients with atrial fibrillation and resulted in fewer bleeding complications. FDA review is in process, the drug is already available in Europe and Canada.

http://content.nejm.org/cgi/content/short/NEJMoa0905561v1

Finally the Chest supplement on latest warfarin use guidelines is linked below.  One item that I did not mention is that recombinant factor VII is an option for reversal.  It is quite expensive but may be an option for patients at risk for developing volume overload with FFP infusion.  Vitamin K doses of 10mg are only recommended in the setting of significant hemorrhage associated with elevated INR.  Intravenous vitamin K should only be considered for immediately life threatening hemorrhage due to the anaphylaxis risk with this mode of infusion.

http://chestjournal.chestpubs.org/content/133/6_suppl/160S.full.pdf