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As an intern, one of the highest-yield schemas I learned was for persistent fevers despite treatment with abx.

I use it all the time as a resident, especially when working with cancer patients.

Let's go through it!

- Thread -

#MedTwitter #MedEd #FOAMed #tipsfornewdocs

1/24
The general ddx for persistent fevers in the hospital, despite abx:

1. Wrong bug
2. Wrong drug
3. Wrong process
4. No source control
5. Not enough time

Let's take them one at a time.

2/24
1. Wrong Bug

When giving abx, we assume it's bacterial, but after some time, you should also consider:

- viruses - ex: CMV, EBV, HBV, HCV
- fungi - ex: candida, aspergillus, PJP, etc
- atypical infections - tickborne, TB, etc.

3/24
Read 24 tweets
A 20-YO ♀️, college wrestling, Mexico: itching in the past 2 months, erythematous & fine-scaling papules with annular plaques having a raised border affecting the face, neck, & torso.
1/6

doi: 10.18502/cmm.6.4.5439
#dermatology #primarycare #MedTwitter
KOH: multiple thin & septate hyphae.
🧫, MALDI-TOF-MS: Trichophyton tonsurans
T. tonsurans was isolated in 4 cases belonging to the school fighting team & from one of the training mats

TINEA GLADIATORUM DUE TO TRICHOPHYTON TONSURANS IN A SCHOLL WRESTLING TEAN
2/6

#mycology
Oral terbinafine for 3 weeks: clinical & mycological cure.
Tinea gladiatorum is a type of dermatophytosis that occurs in combat athletes, such as wrestlers and judo fighters, as a result of Trichophyton species.
3/6

doi: 10.18502/cmm.6.4.5439
#IDtwitter #microbiology #Doctor
Read 6 tweets
A 38-YO♂️, #HIV➕: asthenia, fever, & generalized & confluent maculopapular rash predominantly on the back, cervical & inguinal lymphadenopathies, & stippled petechial hemorrhages in the soft palate (Forchheimer’s spots)
Subsequently, pustules appeared

1/5
#emergency #IDtwitter
Classic Mpox pustules appeared
PCR:
✔️for measles & rubella➖
✔️for Mpox➕

HUMAN Mpox, although confluent maculopapular rash & Forchheimer’s spots have been reported as classic signs of rubella or measles infections
2/5

DOI: doi.org/10.4269/ajtmh.…
#microbiology #MedTwitter
Forchheimer spots, a type of enanthem:
📌sometimes precede the skin rash of rubella.
📌tiny red spots on the soft palate in rubella, measles and scarlet fever.
3/5

#dermatology #internalmedicine #primarycare
Read 5 tweets
ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:
While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?
The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon
Read 13 tweets
1) Antibiotic therapy for community acquired #pneumonia (CAP), according to inpatient/outpatient care & presence of risk factors
mjm.mcgill.ca/article/view/5…
#MedTwitter #MedEd #IDTwitter #healthcare #primarycare #antibiotics #internalmedicine #Bioinformatics #ICU #USMLE #telehealth
2) Flow chart for management of community acquired pneumonia
3) CRB-65, CURB-65, PSI and IDSA-ATS summary
Read 3 tweets
A 27-YO ♀️, fever and PCR + for #SARSCoV2: One week later, she developed migratory, pruritic urticarial erythematous plaques (wheals) on her face, limbs, trunk, palms & soles, and angioedema of her lips.
¼

DOI: doi.org/10.1503/cmaj.2…
#dermtwitter #IDtwitter #MedTwitter
Treated with cetirizine, 12 weeks later, she was still having episodes of urticaria
The most likely diagnosis was CHRONIC SPONTANEOUS URTICARIA TRIGGERED BY SARS-CoV-2, but other considerations were urticarial vasculitis and chronic inducible urticaria.
2/4

#dermatology #Doctor
Urticaria is commonly triggered by viral & bacterial infections, including herpes simplex virus, cytomegalovirus, Epstein–Barr virus, HIV & mycoplasma.

It commonly precedes or occurs concurrently with COVID-19, but can rarely occur after symptoms have resolved.
3/

#virology
Read 4 tweets
A 32-YO♀️ from Guatemala, Ph+ B-ALL post #chemotherapy: #dyspnea
CT: ground-glass opacities (2A yellow box), interstitial pulmonary edema with septal thickening (2B yellow circles), & pericardial effusion (2C yellow arrows), lymph nodes (2D yellow arrows)
Eosinophilia
1/7
Due to normal ejection fraction, the differential diagnosis of dyspnea included non-cardiogenic pulmonary edema, pneumonitis secondary to chemotoxicity, and infection.
2/7

doi.org/10.1016/j.idcr…
#haematology #radiology #IDtwitter
She progressed to acute hypoxic respiratory failure.

🔬bronchoalveolar lavage: numerous larvae (3A,3B) with short buccal grove (arrow head) and prominent genital primordium (arrow) consistent with STRONGYLOIDES HYPERINFECTION

3/7
#lungdisease #parasitology #Pathologists
Read 7 tweets
Ceftriaxone is obviously not a popular choice for MSSA bacteremia among #IDtwitter

There is no prospective data showing it's inferior to other options so far

So why?
First of all, why ceftriaxone?

Most common reason: once daily dosing which makes it good for OPAT

There are 2 flaws here...
1. Once daily dosing

fT>MIC is the 🔑 PK/PD parameter for beta-lactams

Limitations of ceftriaxone:
1. Highly protein bound ➡️lower free drug concentration
2. MIC for MSSA unknown (inferred susceptibility) or too high

Therefore optimal fT>MIC may not be achievable with 2g q24H
Read 7 tweets
#IDtwitter #Immunology A Detailed Overview of #SARSCoV2 #Omicron: Its Sub-variants, Mutations and Pathophysiology, Clinical Characteristics, Immunological Landscape, Immune Escape, and Therapies 🧵
📌mdpi-res.com/d_attachment/v… @VirusesMDPI
📌 sciencedirect.com/science/articl…
Efficacy of Antiviral Agents against Omicron Subvariants BQ.1.1 and XBB
nejm.org/doi/full/10.10… @NEJM
Characterization of #SARSCoV2 recombinants and emerging Omicron sublineages
📌 ncbi.nlm.nih.gov/pmc/articles/P…
📌 medrxiv.org/content/10.110…
📌 biorxiv.org/content/10.110…
Read 4 tweets
A 4-YO♂️ treated for tuberculosis for 3 years with chronic cough, kyphosis, recurrent pneumonia, rib osteomyelitis: lung consolidation, mediastinal lymphadenopathy, cervical kyphosis; R-sided paravertebral soft tissue swelling (T3 to T6)
1/7

#IDtwitter #radiology #Orthopedics
Serology: ➕for Aspergillus flavus & Aspergillus fumigatus.
Aspiration of the paravertebral soft tissue:
🔬granulomatous inflammation
🧫Acinetobacter spp.

VERTEBRAL OSTEOMYELITIS & ACINETOBACTER SPP PARAVERTEBRAL SOFT TISSUE INFECTION
2/7

#microbiology #MedTwitter
Nitroblue tetrazolium dye reduction test: no reduction of the nitroblue tetrazolium
No right shift noted in the activated neutrophils in flow cytometry-based DHR assay (E, patient; F, control)

CHRONIC GRANULOMATOUS DISEASE
3/7

DOI: 10.1097/INF.0000000000001221
#medicine
Read 6 tweets
A 24-YO ♂️ 2 years prior bitten by an insect on his left mid-arm in Nicaraguan: within a week, developed a lesion at the site of the bite; over time increased in number and spread in multiple hyperkeratotic, wart-like papules.
1/8

doi.org/10.1093/cid/ci…
#IDtwitter #dermatology
Wet mount slide from cultures of biopsy using rabbit blood agar slant: aggregates of Leishmania promastigotes (arrow), which can be identified based on their elongated shape and flagella.

CUTANEOUS LEISHMANIASIS
2/8

doi.org/10.1093/cid/ci…
#parasitology #MedTwitter
Biopsy cultures in “triple N” media, PCR and DNA sequencing: Leishmania panamensis.

He received a 10-day course of intravenous liposomal amphotericin B. His lesions slowly regressed over 3 months.
3/8

doi.org/10.1093/cid/ci…
#Doctor #microbiology
Read 8 tweets
Banning Noncompete Clauses by the Federal Trade Commission would dramatically change the structure of medical health networks and greatly increase competition-It may destroy vulnerable medical systems who stand to lose physicians to higher paying neighbors ftc.gov/news-events/ne…
#Noncompete clauses in contracts prevent employees from leaving a business, practice, or company and opening up their own establishment or joining a competitor in a location adjacent to their previous employer. They prevent competition locally. 2/
These clauses protect the company that is losing the individual and prevent employees from leaving unless they choose to move their location. 3/
Read 4 tweets
#idboardreview A college football player w/fever & Left leg hot tender erythema from ankle to mid-calf. There is no nodularity, fluctuance, drainage, purulence, or evidence of lymphangitis. Antibiotic choice? #idtwitter #idmeded #meded pic for ref only
non-purulent cellulitis likely due to strep pyogenes so first gen cephalosporins so cephalexin or cefadroxil is reasonable choice
Ref IDSA SSTI guidelines idsociety.org/practice-guide…
Read 3 tweets
A 27-YO ♂️ with #HIV & #syphilis, condomless receptive & insertive vaginal, anal, & oral intercourse with male & female partners: a diffuse, erythematous, macular rash (involved the palms) & umbilicated, pustular lesions on face, arms (A), legs, trunk (B, flank) & neck (C)
1/7
PCR swabbed lesions:➕for #monkeypox

MONKEYPOX in a sexually-active man with HIV and SYPHILIS

He was started on antiretroviral therapy for his recent diagnosis of HIV, & administered IM benzathine penicillin G for syphilis.
2/7

doi.org/10.1016/j.visj…
#IDtwitter #dermatology
As direct contact is the primary mode of transmission, sexual intimacy has been identified as a risk factor for #Mpox, and a high proportion of the current multinational outbreak has been in men who have sex with men.
3/7

#MedTwitter #Doctor
Read 7 tweets
A 6-YO Bedouin ♂️: a limp, headache, left facial nerve palsy, & left hemiparesis.

Blood eosinophil count of 890/μL.

MRI: a brain cyst.
1/8

DOI: doi.org/10.4269/ajtmh.…
#neurology #pediatric #MedTwitter
Abdominal ultrasound and chest radiography did not reveal additional cysts.
Blood serology (ELISA) for ECHINOCOCCOSIS: ➖

The brain cyst was fully removed surgically.
2/8

DOI: doi.org/10.4269/ajtmh.…
#neuro #Pediatrics #surgery
Histopathological examination of the brain cyst fluid showed several echinococcal larvae (C and D), confirming CYSTIC ECHOCOCCOSIS diagnosis.

Over the following 4 months, he was treated with albendazole without complications.
3/8

#parasitology #microbiology #IDtwitter
Read 8 tweets
🧵1/N How do vaccines and/or natural infection change infectiousness of #COVID19 during #Omicron? Our new article published in @NatureMedicine measures #COVID19 infectiousness, and finds reductions from both vaccine and natural infection. nature.com/articles/s4159…
2/N We use detailed epidemiologic data from SARS-CoV-2 surveillance within the California prison system to study #COVID19 transmission. Our goal was to translate these findings into policy to improve health for this vulnerable incarcerated population that remains at high risk.
3/N We performed a close contact study of index cases with #COVID19 to measure their infectiousness, by comparing their vaccine and natural infection history. We followed their close contact (residents who shared a room) over time to estimate secondary attack rates. Design here:
Read 15 tweets
Mucormycosis:
1. Fatal invasive disease with high mortality
2. Genus: rhizopus, mucor, cunninghamella, lichtheimia etc
3. Risk factors: Uncontrolled DM, DKA, neutropenia, prolonged glucocorticoid use, elevated levels of free iron, SOT, HSCT, COVID-19 infection.
4. Rhino-orbital-cerebral disease: most common form, seen in diabetes, steroid use. Ethmoid sinus-->orbit-->frontal lobe/cavernous sinus, hard palate in advanced case.
5. Pulmonary disease: second most common, in organ transplant, chemotherapy receiving pt.
6. Cutaneous: hematogenous dissemination or direct inoculation. Can be highly invasive. Needs prompt debridement.
7. GIT: GI bleeding, fungating mass seen at UGIE, perforation, high mortality.
8. Disseminated disease: most common site is brain. Mortality >90%.
Read 8 tweets
🧵1/3 #IDtwitter first trivia of 2023!#TxID

45 F w/Hx of hypertensive nephropathy complicated by ESDR s/p kidney transplant 7 mo ago, on tacrolimus & MMF. CMV D+R-, who after completing prophylaxis w/ valganciclovir for 6mo is admitted with 3 wks of watery diarrhea
2/3 Colonoscopy findings consistent with CMV colitis. Initial CMV DNAemia 800 IU/mL. Patient’s immunosuppressive regimen is reduced, and she is treated with ganciclovir 5 mg/kg IV every 12 hours.
3/3 After one week, despite medical treatment diarrhea persists, with up to 6-8 episodes daily.

A repeated CMV DNAemia is 805 IU/mL. What would you do next? 🤔 #IDboardreview
Read 7 tweets
A 39-YO ♂️, same-sex relationships involving condomless anal sex: 38°C, cervical lymphadenopathy, mucosal ulceration on his tongue and a maculopapular rash on his face, neck and anterior chest.
1/5

DOI: doi.org/10.1503/cmaj.2…
#Doctor #emergency #dermatology
RPR: ➖
Immunoassay:➕for HIV antibodies
HIV-1 blood viral load: 4.79 million copies/mL
Blood CD4 T-cell count of 0.1 × 109/L.

ACUTE HIV INFECTION

Started antiretroviral treatment with bictegravir–emtricitabine–tenofovir alafenamide.
2/5

#IDtwitter #microbiology
Features of acute HIV infection occur 2–4 weeks after exposure.
Common presentation includes fever, arthralgia and lymphadenopathy, which may mimic acute mononucleosis.

Seroconversion usually occurs 3–8 weeks after initial infection.
3/5

#virology #MedTwitter
Read 5 tweets
#LongCovid #LandOfTheHypometabolics #IDTwitter #MedTwitter
I find it remarkable that it says "What this means for neurologic Long COVID symptoms remains elusive." Let me lend a HAND.
Viral Persistence In The Central Nervous System Reservoir. Depletion of CD4 cells. Sound familiar? It should. I am talking about HIV Associated Neurocognitive Decline and folk here and yonder have turned a blind eye to how it is prevented.
I wrote this paper on SARS-Cov-2 Associated Neurocognitive Decline. academia.edu/89416437/Milli…
Read 8 tweets
A clinical pearl I learned during a recent stent on clinical service is the relationship between influenza & group A streptococcus (GAS, AKA Strep pyogenes).

Thus, let's commence an #IDTwitter #Tweetorial

/thread
1/ CDC & WHO are reporting increases in GAS in children this winter

I suspect this is due in part to GAS's association with viral respiratory illnesses, in particular flu, but this association isn't exclusive to children or flu

emergency.cdc.gov/han/2022/han00…

who.int/emergencies/di…
2/ Influenza mediates an increased risk in bacterial infection through multiple mechanisms
- ⬆️ bacterial adherence by removing sialic acid
- Mucociliary escalator destruction
- ⬇️ macrophage clearance

ncbi.nlm.nih.gov/pmc/articles/P…
Read 9 tweets
Aspergillosis (disease spectrum, Dx, Rx):
1. Refers collectively to all invasive and allergic disease caused by aspergillus species
2. A.fumigatus: causes most of the invasive & chronic aspergillosis & allergic disease
3. A.flavus: sinus, cutaneous infection & keratitis
4. A.niger: otitis externa
5. It's a hyaline, septate branching mold
6. Risk factors: neutropenia, glucocorticoid use, CGD, severe influenza or Covid-19, COPD, pulmonary TB, infliximab, ibrutinib use, ECMO
7. Invasiv: pulmonary, sinusitis, cutaneous, endocarditis, cerebral
8. Chronic pulmonary aspergillosis(CCPA) : single or multiple cavities in upper lobe, a/w fatigue, weight loss, hemoptysis, prior lung disease like TB etc, untreated can cause fibrosis & destroyed lung
9. Aspergilloma: fungal ball. A/w CPA.
Read 10 tweets
A 3-month-old ♂️, a dimple at the center of a lumbosacral hemangioma (a): fever & deteriorating condition.

CSF: ⬆️cell count 5717/µL;⬆️protein = 352 mg/dL; ⬇️glucose < 10 mg/dL.

RM (b): ?
1/7

doi.org/10.1016/j.idcr…
#pediatric #IDtwitter #Neurology
RM b): a congenital dermal sinus communicating with the spinal cord.

Enterobacter aerogenes was isolated from CSF and stool cultures

CONGENITAL DERMAL SINUS ASSOCIATED WITH MENINGITIS BY ENTEROBACTER AEROGENES
2/7

#radiology #microbiology #pediatria
Congenital dermal sinus is associated with meningitis caused by atypical pathogens.

Enterobacter aerogenes community-acquired infections associated with congenital dermal sinus are rarely observed.
3/7

#bacteriology #MedTwitter
Read 7 tweets

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