November 7, 2017

Recruitment is underway – thank you all for participating in helping us recruit our next group of interns!  We appreciate all the effort and time you put into making our program amazing.

This year, our graduating class had a board pass rate of 96%.  We’re so proud of them!

This week, there will be a CLER (Clinical Learning Environment Review) institutional site visit from the ACGME.  There will be site visitors walking around our hospital who may talk with you a little more about the hospital.

Happy birthday to these November babies!

Alyssa Lampe – November 6
Alexander Becka – November 6
Samuel Tomich – November 12
Mark Slootsky – November 13
Kristen Burton – November 13
James Samuelson – November 17
Jonathan Lerner – November 20
Prachi Nene – November 25
Allen Chao – November 27

11/3/17 Intern Morning Report – Joint pain, Fevers, Recent Diarrheal Illness, Oligoarthritis, HIV, Reactive Arthritis

CC: Joint Pain

HPI: This is a 32 year old male with history of chlamydia and new diagnosis of HIV who presents for painful joint swelling in bilateral knees and wrists for 5 days. He reports that approximately 3 weeks prior to admission, he experienced 1 week of abdominal pain, diarrhea, and fevers. While the GI symptoms resolved, he has had on and off fevers since. Five days prior to admission, he began to have bilateral wrist pain with swelling which then progressed to to his left knee followed by his right knee over the course of a few days. His social history is notable for being sexually active with both males and females with greater then 30 partners over the last few years.  His exam is pertinent for bilateral wrist and knee swelling, warmth and tenderness. There is difficulty ranging the joints with both passive and active motion.  Skin and lymph node exam is normal though.  Given history and exam consistent with an inflammatory oligoarthritis in the setting of recent gastrointestinal infection, reactive arthritis high on the differential but could not rule out disseminated gonococcal infection or atypical presentation of crystalopathy, septic joint, or rheumatoid arthritis.  Joint aspiration from wrist significant for a leukocyte count of >90,000 with >75% PMNs so patient initiated on antibiotic therapy for septic joint treatment.  However further studies on synovial fluid unrevealing including gram stain, culture, and crystals.  Serologies were also sent which showed a negative ANA, mildly elevated RF, and negative Anti-CCP.  Mucosal swabs for gonorrhea negative and though patient high risk, without other findings of disseminated gonococcal infection (DGI) like tenosynovitis, pustular rash, and migratory arthritis nor positive cultures from non-mucosal sites, DGI considered unlikely. With the clinical picture involving a recent diagnosis of HIV as well as a diarrheal illness in addition to negative infectious and crystallopathy work up, a diagnosis of reactive arthritis was made.

Some Notable Labs:

Wrist Synovial Fluid:
(H) 96,000 leukocytes/cumm
(H) 92 % PMNs

Gram stain and culture negative

  • CRP 170 (>7 high)
  • ESR 90 (0-22)
  • ANA Negative
  • RF: 58 (normal high 13)
  • Anti-CCP: <16
  • HLA B27 Positive

Right sided supra patellar effusion, otherwise normal X-rays.


Morning Report Pearls:

Though cases do not always fit the classic presentation, it can be useful to breakdown etiologies of joint complaints by the number involved.

Monoarthritis Differential

Oligoarthritis (2-4 joints) Differential

Polyarthritis (>5 joints) Differential

1. Acute Infection: Bacterial

2. Subacute/Chronic Infection: Fungal, TB, Lyme

3. Crystal Disease: CPPD, Gout

4. Osteoarthritis

5. Trauma

6. Monoarticular Rheumatoid Arthritis

1. Spondyloarthropathies: AS, Psoriatic arthritis, Reactive arthritis, IBD

2. Disseminated Gonococcal

3. Rheumatic Fever

4. Lyme Disease

5. Osteoarthritis

1. Chronic inflammatory: Rheumatoid arthritis, SLE, Psoriatic, Vasculitis

2. Acute Viral: Hepatitis, Parvo, Rubella, HIV, Enterovirus

3. Drug Induced Serum Sickness

 

 

Synovial Fluids Studies are important in differentiating non-inflammatory conditions from inflammatory. Also the degree of leukocyte elevation can provide useful information for determining an etiology.

Synovial Fluid Leukocyte Count:

<200 = Normal

200-2,000 = Non-Inflammatory

2,000 = Inflammatory

50,000 = High Concern for Septic Joint however Crystal Disease, Reactive Arthritis and other autoimmune disorders like Rheumatoid Arthritis can not be completely excluded

 

Mildly elevated Rheumatoid Factor occurs in the general healthy population and also be positive in certain infections and/or autoimmune conditions.  RF is very sensitive for the diagnosis of Rheumatoid Arthritis but that means it can include a higher number of false positives so mildly elevated results in the incorrect clinical picture needs to be scrutinized.  The fact that Anti-CCP is negative, a specific test, makes RA diagnosis less likely in this case as well.

10/25/17 Resident Morning Report – Shortness of Breath, Fevers, Cough, Pleural Effusion, Pleural TB

CC: Shortness of breath, Cough

ID: This is a 20 yo female with no significant past medical history who presents with cough and shortness of breath for 2 weeks.  Three days into her course, she was diagnosed with pneumonia at an outside emergency department and was discharged home with a course of amoxicillin.  However, her symptoms worsened despite 6 days of antibiotics. New symptoms appeared a few days prior to admission including including pleuritic chest pain, worsening shortness of breath when supine, chills as well as fevers. Of note, patient is from Mexico and moved to the United States at 6 years-old.  Her family frequently visits her from Mexico, the last visit occurring one month ago. On exam patient is febrile to 39.8 degrees Celsius, tachycardic to 130 with significant findings of decrease breath sounds on the left side in addition to decrease fremitus and dullness to percussion. CXR obtained showed a large effusion that layered out on lateral decubitus position. Pleural fluid returned consistent with a lymphocyte predominant, exudative process.  Cytology was sent twice which showed no atypical cells but an elevated adenosine deaminase was detected making Pleural Tuberculosis highest on the differential.  Given the suspicion for extra pulmonary TB, a pleural biopsy was pursued and patient was empirically started on RIPE therapy. Pleural biopsy showed necrotizing granulomas but AFB stain negative.  Four weeks later, cultures from pleural fluid and pleural biopsy grew out Mycobacterium Tuberculosis.

 

CXR:

Pleural Fluid Analysis:

  • Nucleated Cells 372/cumm
  • Segmented Neutrophils 6%
  • Lymphocytes 72%
  • Monocytes 22%
  • Serum LDH 194
  • Serum Protein 8.2
  • Pleural Fluid Protein/Total Serum Protein = 0.7
  • Pleural Fluid LDH/Serum LDH = 3.3
  • pH 7.31
  • Glucose 70
  • Adenosine Deaminase 60

Pleural Biopsy:


Morning Report Pearls:

When an exudative effusion is diagnosed using Light’s Criteria, it is important to check that it is not a pseudoexudate which can occur due to inherent errors in using protein and LDH pleural/serum ratios but particularly in the setting of diuretic use.  If pleural albumin – serum albumin >1.2 then this is consistent with a pseudoexudate and the fluid likely represents a transudative effusion rather then exudative.  Pleural fluid total protein – serum total protein >3.1 can also be used instead of the albumin gradient.

 

Nucleated cell counts are useful in differentiating etiologies:

 

It is important to define if a parapneumonic effusion in a non-resolving pneumonia is complicated or an empyema.  Luckily with our patient, this was not the case.  However if diagnosed with either, management changes as the patient requires drainage of the effusion in addition to antibiotic therapy:

 

Given this patient had a true lymphocytic exudative effusion in the setting of tuberculosis risk factors, an adenosine deaminase was correctly sent. It is important to remember the utility of the various TB studies:

  • Smear and culture of pleural fluid for AFB is very specific but low sensitivity of around 5%
  • Adenosine deaminase is elevated in most tuberculosis pleural effusion with a sensitivity around 95%
  • Pleural biopsy is the most likely to yield a positive mycobacterial culture, greater then 70%