Discover and read the best of Twitter Threads about #GalactoMagic
Most recents (14)
1/
First of 2 tweets! #GalactoMagic
80F nursing home resident presents w/ 3 days of fever, cough, & SOB
Vitals: T 38.6C, HR 110, BP 120/80, O2 94% on 3L. Exam notable for left basilar rhonchi & crackles
CXR shows LLL opacity. She is started on ceftriaxone & doxy
First of 2 tweets! #GalactoMagic
80F nursing home resident presents w/ 3 days of fever, cough, & SOB
Vitals: T 38.6C, HR 110, BP 120/80, O2 94% on 3L. Exam notable for left basilar rhonchi & crackles
CXR shows LLL opacity. She is started on ceftriaxone & doxy
2/
2 days later, she is still having intermittent fevers with Tmax 38.1C, O2 94% on 3L, RR 30
A CT chest reveals a dense LLL consolidation
In addition to sputum cultures, which of the following tests should be ordered?
2 days later, she is still having intermittent fevers with Tmax 38.1C, O2 94% on 3L, RR 30
A CT chest reveals a dense LLL consolidation
In addition to sputum cultures, which of the following tests should be ordered?
1/12
Answer: Blood cultures
The patient is a nursing home resident w/ ongoing fevers, hypoxia, high RR, with a LLL consolidation
In addition to sputum cx, the patient should also have blood cx (fits pneumonia severity index IV)
There is no dysuria to prompt an UA
Answer: Blood cultures
The patient is a nursing home resident w/ ongoing fevers, hypoxia, high RR, with a LLL consolidation
In addition to sputum cx, the patient should also have blood cx (fits pneumonia severity index IV)
There is no dysuria to prompt an UA
1/
First of 2 tweets! #GalactoMagic
65F presents w/ 8 days of SOB. T 38C, HR 115, BP 100/60, RR 22, O2 92% on 100% non-rebreather & then intubated
Exam notable for crackles. CT chest shows GGO bilaterally
She has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
First of 2 tweets! #GalactoMagic
65F presents w/ 8 days of SOB. T 38C, HR 115, BP 100/60, RR 22, O2 92% on 100% non-rebreather & then intubated
Exam notable for crackles. CT chest shows GGO bilaterally
She has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
2/
After remdesivir, dexamethasone, ceftriaxone & doxy, she defervesces. 3 weeks later, she has worsening SOB
Repeat CT chest shows worsening GGO & new pulm nodules
Which of the following is the most sensitive diagnostic modality for COVID-19 associated pulmonary aspergillosis?
After remdesivir, dexamethasone, ceftriaxone & doxy, she defervesces. 3 weeks later, she has worsening SOB
Repeat CT chest shows worsening GGO & new pulm nodules
Which of the following is the most sensitive diagnostic modality for COVID-19 associated pulmonary aspergillosis?
1/11
Answer: BAL fluid culture
Although the most feasible test would be a tracheal aspirate culture, the highest yield test for Aspergillus is the BAL fluid culture
🌞Serum GM and BDG lack sensitivity compared to BAL testing
Answer: BAL fluid culture
Although the most feasible test would be a tracheal aspirate culture, the highest yield test for Aspergillus is the BAL fluid culture
🌞Serum GM and BDG lack sensitivity compared to BAL testing
1/
First of 2 tweets! #GalactoMagic
50F w/ EtOH cirrhosis & DM presents to ED w/ AMS & decreased UOP. She is febrile & hypotensive
She is started on vasopressors & CVVHD via central lines in the ICU
Due to concern for SBP, she is started on ceftriaxone
First of 2 tweets! #GalactoMagic
50F w/ EtOH cirrhosis & DM presents to ED w/ AMS & decreased UOP. She is febrile & hypotensive
She is started on vasopressors & CVVHD via central lines in the ICU
Due to concern for SBP, she is started on ceftriaxone
2/
Initial blood & ascites cultures show no growth. She remains critically ill for 7 days and still having fevers
In addition to blood cultures, which of the following is the next best test to order?
Initial blood & ascites cultures show no growth. She remains critically ill for 7 days and still having fevers
In addition to blood cultures, which of the following is the next best test to order?
1/13
Answer: Serum BDG
You have suspicion for invasive candidiasis given the RF of cirrhosis, critical illness in ICU w/ central lines, dialysis, & broad-spectrum antibiotics (see other RF in table)
Answer: Serum BDG
You have suspicion for invasive candidiasis given the RF of cirrhosis, critical illness in ICU w/ central lines, dialysis, & broad-spectrum antibiotics (see other RF in table)
1/
First of 2 tweets! #GalactoMagic
45F w/ chronic lung disease and bronchiectasis presents to clinic w/ a chronic cough for the past 3 months.
She works as a construction worker in California. Exam is notable for poor dentition
First of 2 tweets! #GalactoMagic
45F w/ chronic lung disease and bronchiectasis presents to clinic w/ a chronic cough for the past 3 months.
She works as a construction worker in California. Exam is notable for poor dentition
2/
CT chest shows several nodules bilaterally in lung parenchyma with some cavitations
A bronch w/ BAL is performed & shows gram-positive bacilli, & a serum beta-d-glucan (BDG) is positive at 110 (positive > 80)
What is the likely cause of the BDG elevation?
CT chest shows several nodules bilaterally in lung parenchyma with some cavitations
A bronch w/ BAL is performed & shows gram-positive bacilli, & a serum beta-d-glucan (BDG) is positive at 110 (positive > 80)
What is the likely cause of the BDG elevation?
1/8
Answer: Nocardia
All of these bacteria are gram + bacilli, but only nocardia causes BDG elevation
Other bacteria that cause +BDG include pseudomonas & mycobacteria
For a review of “false positives” & test characteristics of both BDG/GM, this figure is really helpful
Answer: Nocardia
All of these bacteria are gram + bacilli, but only nocardia causes BDG elevation
Other bacteria that cause +BDG include pseudomonas & mycobacteria
For a review of “false positives” & test characteristics of both BDG/GM, this figure is really helpful
A one tweet question! #GalactoMagic
60M w/ asthma from China presents w/ SOB secondary to an asthma exacerbation. He has never smoked cigarettes. A CT chest shows a 7mm right upper lobe nodule
Which of the following tests should be ordered for further evaluation of the nodule?
60M w/ asthma from China presents w/ SOB secondary to an asthma exacerbation. He has never smoked cigarettes. A CT chest shows a 7mm right upper lobe nodule
Which of the following tests should be ordered for further evaluation of the nodule?
1/14
Answer: AFB sputum culture
Without knowing much about the patient, other than age, geographic risk, smoking status, & normal immune status, most common infectious cause of a solitary pulmonary nodule (SPN) is TB.
Answer: AFB sputum culture
Without knowing much about the patient, other than age, geographic risk, smoking status, & normal immune status, most common infectious cause of a solitary pulmonary nodule (SPN) is TB.
2/
It’s possible that the SPN may be latent TB, but we need to rule out active TB first (AFB sputum cultures x3) before considering latent TB
Fungal causes are less likely. If we want to work it up, it would be pathogen specific (e.g., Cocci Ab) & not broad antigen testing (BDG)
It’s possible that the SPN may be latent TB, but we need to rule out active TB first (AFB sputum cultures x3) before considering latent TB
Fungal causes are less likely. If we want to work it up, it would be pathogen specific (e.g., Cocci Ab) & not broad antigen testing (BDG)
1/
First of 2 tweets! #GalactoMagic
75F w/ lupus, HTN, recent diagnosis of HIV (viral load 30,000, CD4- 57), presents to ED in winter w/ 4 weeks of shortness of breath & cough. T 38.5C, HR 105, BP 105/80, RR 20, O2 94% on 3L. Exam is notable for crackles & rhonchi in both lungs
First of 2 tweets! #GalactoMagic
75F w/ lupus, HTN, recent diagnosis of HIV (viral load 30,000, CD4- 57), presents to ED in winter w/ 4 weeks of shortness of breath & cough. T 38.5C, HR 105, BP 105/80, RR 20, O2 94% on 3L. Exam is notable for crackles & rhonchi in both lungs
2/
Labs: WBC 2,600, Hb 7.5 g/dL, platelet 70,000. CXR shows diffuse opacities. You have suspicion for Pneumocystis jirovecii pneumonia
Which of the following is the best non-invasive test to order to help confirm the diagnosis?
Labs: WBC 2,600, Hb 7.5 g/dL, platelet 70,000. CXR shows diffuse opacities. You have suspicion for Pneumocystis jirovecii pneumonia
Which of the following is the best non-invasive test to order to help confirm the diagnosis?
1/11
Answer: Serum BDG
⭐️LDH elevation is nonspecific and can be elevated in many diffuse pulm processes
Serum GM is not helpful in diagnosing PJP since its cell wall does not contain GM
BDG is a cell wall polysaccharide present in many pathogenic fungi including P. jirovecii
Answer: Serum BDG
⭐️LDH elevation is nonspecific and can be elevated in many diffuse pulm processes
Serum GM is not helpful in diagnosing PJP since its cell wall does not contain GM
BDG is a cell wall polysaccharide present in many pathogenic fungi including P. jirovecii
1/
First of 2 tweets! #GalactoMagic
65F w/ history of heart transplant on tacrolimus, prednisone, & mycophenolate, presents w/ SOB and fatigue. Vitals are normal. Exam is notable for tender red bumps on the shins bilaterally. Labs are notable for absolute eosinophil count of 800
First of 2 tweets! #GalactoMagic
65F w/ history of heart transplant on tacrolimus, prednisone, & mycophenolate, presents w/ SOB and fatigue. Vitals are normal. Exam is notable for tender red bumps on the shins bilaterally. Labs are notable for absolute eosinophil count of 800
2/
CT chest shows scattered pulmonary nodules throughout. The team decides to order a serum beta-d-glucan (BDG)
Which of the following potential causes of her skin and pulmonary nodules is most likely to result in a positive serum BDG?
CT chest shows scattered pulmonary nodules throughout. The team decides to order a serum beta-d-glucan (BDG)
Which of the following potential causes of her skin and pulmonary nodules is most likely to result in a positive serum BDG?
1/14
Answer: Cocci!
Although no epi history was provided here, you can use several clues to get to the answer: eosinophilia, erythema nodosum, and +BDG
Although Crypto and Blasto can rarely cause +BDG, Cocci is much more likely to have a positive BDG
pubmed.ncbi.nlm.nih.gov/29125373/
Answer: Cocci!
Although no epi history was provided here, you can use several clues to get to the answer: eosinophilia, erythema nodosum, and +BDG
Although Crypto and Blasto can rarely cause +BDG, Cocci is much more likely to have a positive BDG
pubmed.ncbi.nlm.nih.gov/29125373/
1/
First of 2 tweets! #GalactoMagic
60M presents w/ 7 days of fevers & SOB. T 38.1C, HR 105, BP 110/70, RR 22, O2 95% on 6L & then intubated. Exam notable for diffuse crackles. CT chest shows GGO bilaterally. He has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
First of 2 tweets! #GalactoMagic
60M presents w/ 7 days of fevers & SOB. T 38.1C, HR 105, BP 110/70, RR 22, O2 95% on 6L & then intubated. Exam notable for diffuse crackles. CT chest shows GGO bilaterally. He has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
2/
After remdesivir, dexamethasone, ceftriaxone & doxy, he defervesces. 3 weeks later, he has worsening SOB. Repeat CT chest shows RUL cavitation. Serum BDG is 75 (positive>80) & serum GM is 0.4 (positive>0.5)
Which of the following diagnostics would have the highest yield?
After remdesivir, dexamethasone, ceftriaxone & doxy, he defervesces. 3 weeks later, he has worsening SOB. Repeat CT chest shows RUL cavitation. Serum BDG is 75 (positive>80) & serum GM is 0.4 (positive>0.5)
Which of the following diagnostics would have the highest yield?
1/13
Answer: BAL fluid culture
This patient is suffering from severe COVID-19 and is at risk for both bacterial and fungal super-infections
Although the most feasible test would be a sputum culture, the highest yield test for both bacteria and fungi is the BAL fluid culture
Answer: BAL fluid culture
This patient is suffering from severe COVID-19 and is at risk for both bacterial and fungal super-infections
Although the most feasible test would be a sputum culture, the highest yield test for both bacteria and fungi is the BAL fluid culture
1/
First of 2 tweets! #GalactoMagic
44M from Maine w/ myelodysplastic syndrome s/p BMT 6 weeks ago has fevers. He is on voriconazole, moxifloxacin, atovaquone, & valacyclovir. He is taking topical steroids for the past 25 days due to mild skin graft versus host disease.
First of 2 tweets! #GalactoMagic
44M from Maine w/ myelodysplastic syndrome s/p BMT 6 weeks ago has fevers. He is on voriconazole, moxifloxacin, atovaquone, & valacyclovir. He is taking topical steroids for the past 25 days due to mild skin graft versus host disease.
2/
T 38.2C, HR 101, BP 115/80, RR 16, O2 98% on RA. Labs notable for WBC 1000 (neutrophil count 200), hemoglobin 6.1, platelets 3,000. Which of the following puts the patient at increased risk for developing invasive aspergillosis?
T 38.2C, HR 101, BP 115/80, RR 16, O2 98% on RA. Labs notable for WBC 1000 (neutrophil count 200), hemoglobin 6.1, platelets 3,000. Which of the following puts the patient at increased risk for developing invasive aspergillosis?
1/10
Answer: Neutropenia. Prolonged neutropenia is one of the biggest RF for aspergillosis. A CD4 count <100 and systemic corticosteroids are additional risk factors for invasive pulmonary aspergillosis (IPA)
For additional RF, please see the following table
Answer: Neutropenia. Prolonged neutropenia is one of the biggest RF for aspergillosis. A CD4 count <100 and systemic corticosteroids are additional risk factors for invasive pulmonary aspergillosis (IPA)
For additional RF, please see the following table
1/
First of 2 tweets! #GalactoMagic
30M from Indiana w/ peptic ulcer disease presents w/ abdominal pain & hematemesis. He reports taking ibuprofen 4000mg daily for the past 3 weeks. T 38.5C, HR 120, BP 100/60, RR 18, O2 93% on RA. Labs notable for WBC 11,000, Hb 4, plt 155,000
First of 2 tweets! #GalactoMagic
30M from Indiana w/ peptic ulcer disease presents w/ abdominal pain & hematemesis. He reports taking ibuprofen 4000mg daily for the past 3 weeks. T 38.5C, HR 120, BP 100/60, RR 18, O2 93% on RA. Labs notable for WBC 11,000, Hb 4, plt 155,000
2/
Over the next 2 days, the patient receives 10 units of blood products. On day 3, the patient has a fever. A serum beta-d-glucan is ordered and results at 90 (positive > 80). What is the likely cause of the beta-d-glucan elevation?
Over the next 2 days, the patient receives 10 units of blood products. On day 3, the patient has a fever. A serum beta-d-glucan is ordered and results at 90 (positive > 80). What is the likely cause of the beta-d-glucan elevation?
1/11
Answer: Positive from blood products
🍎Patient developed an upper GI bleed from excess ibuprofen, requiring 10 units of blood products
🍊Blood products can contain glucans, and once infused into patients, it may cause a positive serum BDG. Plasma and IVIg can also do this
Answer: Positive from blood products
🍎Patient developed an upper GI bleed from excess ibuprofen, requiring 10 units of blood products
🍊Blood products can contain glucans, and once infused into patients, it may cause a positive serum BDG. Plasma and IVIg can also do this
1/
First of 2 tweets! #GalactoMagic
55F w/ COPD has 3 days of fevers, SOB & cough. T 38.2C, HR 112, BP 100/75, RR 22, O2 93% on 100% non-rebreather. Exam- crackles b/l
CT chest- ground-glass opacities b/l
Rapid flu swab + for influenza A, sputum & blood cultures negative
First of 2 tweets! #GalactoMagic
55F w/ COPD has 3 days of fevers, SOB & cough. T 38.2C, HR 112, BP 100/75, RR 22, O2 93% on 100% non-rebreather. Exam- crackles b/l
CT chest- ground-glass opacities b/l
Rapid flu swab + for influenza A, sputum & blood cultures negative
2/
W/ oseltamivir, ceftriaxone & azithro, she defervesces. 3 wks later, has fevers & worsening SOB. Repeat CT chest- new 2cm RUL cavitary lesion. Resp viral panel +influenza A, blood & sputum cultures neg. Which of the following is the most likely cause of the cavitary lesion?
W/ oseltamivir, ceftriaxone & azithro, she defervesces. 3 wks later, has fevers & worsening SOB. Repeat CT chest- new 2cm RUL cavitary lesion. Resp viral panel +influenza A, blood & sputum cultures neg. Which of the following is the most likely cause of the cavitary lesion?
1/11
Answer: Pulmonary aspergillosis. Patient has several RF for pulm aspergillosis including COPD, critical illness, and severe influenza infection. As a refresher, here is a table with RF for aspergillosis
Answer: Pulmonary aspergillosis. Patient has several RF for pulm aspergillosis including COPD, critical illness, and severe influenza infection. As a refresher, here is a table with RF for aspergillosis
1/
This is the first of 2 tweets! #GalactoMagic
37M w/ cirrhosis on the liver transplant list has been in the ICU for 1 week for management of hepatorenal syndrome. His initial presentation was notable for fevers & dyspnea, but he was otherwise hemodynamically stable w/o hypoxia
This is the first of 2 tweets! #GalactoMagic
37M w/ cirrhosis on the liver transplant list has been in the ICU for 1 week for management of hepatorenal syndrome. His initial presentation was notable for fevers & dyspnea, but he was otherwise hemodynamically stable w/o hypoxia
2/
His fevers continued & then developed worsening hypoxemia requiring 2L O2. CT chest showed bilateral sub-centimeter lung nodules. Labs are sent and a diagnosis of Crypto is made. Serum beta-d-glucan later results; what would you expect its value to be? (ref range <31 pg/mL)?
His fevers continued & then developed worsening hypoxemia requiring 2L O2. CT chest showed bilateral sub-centimeter lung nodules. Labs are sent and a diagnosis of Crypto is made. Serum beta-d-glucan later results; what would you expect its value to be? (ref range <31 pg/mL)?
1/7
Answer: <31. We've learned that there are 3 fungi that don't cause a + serum BDG: Blasto, Mucorales, Crypto. Looking at the Venn diagram, crypto is on the perimeter of the BDG circle. Crypto rarely causes a +BDG, and when it does, it's low level +
pubmed.ncbi.nlm.nih.gov/29125373/
Answer: <31. We've learned that there are 3 fungi that don't cause a + serum BDG: Blasto, Mucorales, Crypto. Looking at the Venn diagram, crypto is on the perimeter of the BDG circle. Crypto rarely causes a +BDG, and when it does, it's low level +
pubmed.ncbi.nlm.nih.gov/29125373/
1/
This is the first of 2 tweets! #GalactoMagic
62M w/ PMHx of liver transplant 8 months ago presents w/ 3 weeks of cough & fevers. He recently moved from Indiana (where he had his transplant) to Florida. He has been adherent to his meds (tacro, mycophenolate, pred, trim/sulfa)
This is the first of 2 tweets! #GalactoMagic
62M w/ PMHx of liver transplant 8 months ago presents w/ 3 weeks of cough & fevers. He recently moved from Indiana (where he had his transplant) to Florida. He has been adherent to his meds (tacro, mycophenolate, pred, trim/sulfa)
2/
T 38.1C, HR 99, BP 115/85, RR 16, 95% on RA. Exam notable for shallow ulcer on soft palate. CT chest shows new nodules bilaterally in lung parenchyma. Serum BDG assay is 85 (positive>80), serum GM index is 0.55 (positive>0.5). Patient likely has which infection?
T 38.1C, HR 99, BP 115/85, RR 16, 95% on RA. Exam notable for shallow ulcer on soft palate. CT chest shows new nodules bilaterally in lung parenchyma. Serum BDG assay is 85 (positive>80), serum GM index is 0.55 (positive>0.5). Patient likely has which infection?
1/8
This patient from Indiana had a liver transplant 8 months ago & presented w/ a palate ulcer, pulm nodules, & a positive BDG & GM, all of which point to disseminated histo
This patient from Indiana had a liver transplant 8 months ago & presented w/ a palate ulcer, pulm nodules, & a positive BDG & GM, all of which point to disseminated histo
Next question!
1/
This is the first of 2 tweets! #GalactoMagic
40M with no PMHx presents to ED with 3 days of fever, cough, & SOB. Vitals: T 39C, HR 120, BP 130/80, O2 93% on 4L. Exam notable for R basilar rhonchi & crackles. CXR shows RLL opacity. He is started on ceftriaxone
1/
This is the first of 2 tweets! #GalactoMagic
40M with no PMHx presents to ED with 3 days of fever, cough, & SOB. Vitals: T 39C, HR 120, BP 130/80, O2 93% on 4L. Exam notable for R basilar rhonchi & crackles. CXR shows RLL opacity. He is started on ceftriaxone
2/
4 days later, he is still having intermittent fevers with Tmax 38.1C, O2 94% on 2L. He does not have dysuria or hematuria. The team orders a CT chest, which reveals a dense RLL consolidation. In addition to sputum cultures, which of the following tests should be ordered?
4 days later, he is still having intermittent fevers with Tmax 38.1C, O2 94% on 2L. He does not have dysuria or hematuria. The team orders a CT chest, which reveals a dense RLL consolidation. In addition to sputum cultures, which of the following tests should be ordered?
1/10
Here, the patient has ongoing fevers and hypoxia, with a CT that shows a RLL consolidation. In addition to sputum cultures, the patient should also have blood cultures obtained to complete the fever work up. There is no dysuria or hematuria to prompt the ordering of an UA
Here, the patient has ongoing fevers and hypoxia, with a CT that shows a RLL consolidation. In addition to sputum cultures, the patient should also have blood cultures obtained to complete the fever work up. There is no dysuria or hematuria to prompt the ordering of an UA
