4/21/17 Intern Morning Report – Diarrhea, Hyponatremia, Cryptosporidia

CC: RUQ pain and diarrhea x 6 weeks

ID: 58 yo male with HIV/AIDS (CD4 25) off HAART who presents with 6-8 weeks of persistent cramping, non-radiating RUQ pain, and watery diarrhea.  He was found to have hypovolemic hyponatremia and ultimately work-up revealed cryptosporidium.

Capture

Source: MKSAP 17


Pearls from morning report:

  • Blastocystis species are commonly detected in stool samples, but it is unclear whether this parasite is truly pathogenic. In symptomatic patients who are immunocompromised, a thorough examination for infections and noninfectious causes should be performed. If the work up is negative, then treatment with blastocystis with metronidazole is a reasonable option
  • Ecstasy can cause drug-induced ADH secretion leading to hypotonic hyponatremia.

Random trivia:

Cryptosporidium is the most common cause of recreational water illness outbreaks – caution next time you go to Raging Waters!


Want to read more?

Disorders of Plasma Sodium – Causes, Consequences, and Correction (New England Journal of Medicine)
Hyponatremia (New England Journal of Medicine)


References: 

Sterns RH, Emmett M, Forman JP. Diagnostic evaluation of adults with hyponatremia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May 3, 2017)

Sterns RH, Emmett M, Forman JP. Causes of hyponatremia in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May 3, 2017)

MKSAP 17: Medical Knowledge Self-assessment Program. Philadelphia : American College Of Physicians, 2016. Print.

3/28/17 Resident Morning Report – Eosinophilia, Eosinophilic Pneumonia

CC: dyspnea

ID: 40 yo female presents with 7 weeks of progressively worsening dyspnea and non-productive cough that have persisted despite a course of azithromycin.  She was found to have diminished breath sounds bilaterally and a CBC with WBC of 20.3 and 43% eosinophils.  She denied any recent travels, but admits to frequent “purification rundown” treatments with the Church of Scientology.  She underwent a BAL that showed predominant eosinophils and a thoracentesis with 85% eosinophils.  She was ultimately diagnosed with chronic eosinophilic pneumonia, thought to be secondary to her purification treatments (high doses of niacin).  She was started on steroids with improvement in symptoms; however, each time she stopped steroid therapy and got more purification treatments, her symptoms would flare up.

Don’t forget:

The causes for peripheral eosinophilia can be broadly categorized into 2 mnemonics: CHINA or NAACP.

  • C – connective tissue disease
  • H – helminthic disease
  • I – idiopathic/iatrogenic
  • N – neoplastic
  • A – allergic/asthma
  • N – neoplastic
  • A – allergic
  • A – asthma/atopic
  • C – connective tissue disease
  • P – parasites

Pearls from morning report:

  • An absolute eosinophil count (AEC) > 20,000 should raise suspicion for malignancy.
  • Bacterial infections very rarely cause eosinophilia.
  • > 25% eosinophils on BAL is suggestive of a diagnosis of acute eosinophilic pneumonia, and > 40% for chronic eosinophilic pneumonia.
  • Chronic eosinophilic pneumonia may appear on CXR as ‘photographic negative of pulmonary edema’ and is considered pathognomonic for the disease.

Random trivia:

Purification rundown treatments were developed by the Church of Scientology founder L. Ron Hubbard.  The goal goal was designed to remove LSD from the body using a restricted diet and large doses of vitamins.


Want to read more?

Eosinophilia (The New England Journal of Medicine)
Eosinophilic Lung Disease (Clinical Chest Medicine)


References: 

Weller PF, Klion AD, Mahoney DH, Bochner BS, Rosmarin AG, Feldweg AM. Approach to the patient with unexplained eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)

Klion AD, Weller PF, Bochner BS, Hollingsworth H. Causes of pulmoanry eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)

2/17/17 Intern Morning Report – Red Eye, CMV Retinitis

CC: 1 week of redness of the eye

ID: 54 yo male with HIV/AIDS (CD4 count 96 2 months ago), noncompliant with medications, who presents with redness of the eye for 1 week and blurry vision for 1 month.  Retinal exam was notable for inferior large chorioretinal scar with focal white lesion within the scar, consistent with CMV retinitis.  AC tap was positive for CMV and negative for VZV or HSV.  He was found to have a repeat CD4 count of 34.

red-eye-flowchart

American Academy of Ophthalmology webpage on ophthalmic abbreviations.


Pearls from morning report:

  • For patients with CD4 < 50, remember to get regular ophthalmology exams every 3-6 months.
  • CMV retinitis can be diagnosed based on fundoscopic exam alone – a vitreous tap is not required for diagnosis.
  • CMV retinitis can present as part of the immune reconstitution inflammatory syndrome (IRIS).

Random trivia:

When first discovered, ganciclovir was so efficacious that a placebo-controlled clinical trial could not be ethically be done – the FDA rejected the first application to market the drug.  The pharmaceutical company who developed this drug, Syntex, gave the drug away for free for 5 years under compassionate use guidelines.


Want to read more?

Ocular Emergencies (American Family Physician)
What can you see in your patient’s eyes? Review of ocular manifestations of HIV in HAART era (International Journal of STD & AIDS)


References: 

MKSAP 17: Medical Knowledge Self-assessment Program. Philadelphia : American College Of Physicians, 2016. Print.

Jacobs DS, Trobe J, Libman H. Evaluation of the red eye. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 17, 2017)