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A patient living with HIV with undetectable viral loads for many years asks you if they can stop their antiretroviral therapy (ART). What is the right answer and what is the underlying reason?


#MedEd #MedTwitter #FOAMed #IDTwitter
The answer is straight-forward: DO NOT STOP!
HIV is notorious for establishing a latent infection in a wide range of cell populations inside body. The lymphoid tissue is the major reservoir. (2/n)
As a result, there is a rebound viremia following the discontinuation of the ART originating from these reservoirs. (3/n)
Read 6 tweets
#IDSA AMR Updates 2023
Updates in ESBL E
To avoid piptaz in non UTI
To avoid Cefepime
No role of Cephamycins
No role of Ceftalazone - Tazobactam
@idcon2022 @id_cure
@IDstewardship ImageImageImageImage
Updates in AmpC
Explained well about How to choose Antibiotics in AmpC - ImageImageImage
Updates in CRE -
Explicitly mentions TOC for NDM, OXA, KPC & while awaiting reports.
No role of Tetracycline derivatives in UTI/ BSI ImageImageImageImage
Read 6 tweets
Metformin's benefit for #COVID19 is from an anti-viral effect.
3.6-fold greater reduction in #SARSCOV2 viral load over placebo equating to: -0.56 log10 copies/mL (95%CI, -1.05 to -0.06,p=0.027) #IDTwitter…
We observed no virologic effect of #ivermectin at median of 430 mcg/kg/day x3 days or of low-dose #fluvoxamine at 50mg 2x/d.
Metformin Virologic Effect was generally consistent across subgroups, larger in the unvaccinated at -0.773 log10 copies/mL (95%CI, -1.408 to -.139) Image
Metformin is a $1 therapy.
At Day 5 antiviral effect over placebo was 0.47 log10 copies/mL for metformin, 0.30 log10 copies/mL for molnupiravir, & 0.80 log10 copies/mL for nirmatrelvir; and at Day 10 was 0.64 log10 copies/mL for metformin and 0.35 log10 copies/mL for nirmatrelvir
Read 14 tweets
A 44-yo♂️, HIV +, CD4 cell count of 86/mL, viral load of 35,900 copies/mL: a 1-month history of fevers and pruritic blackish-brown lamellated plaques on the limbs and scalp.
DOI: 10.1056/NEJMicm2213894
#IDtwitter #dermatology Ming J. Liu, M.D., and Wei ...
A RPR titer of 1:32.
A Treponema pallidum particle agglutination: ➕.
A skin-biopsy of the left forearm 🔬: diffuse dermal lymphocytes and histiocytes admixed with a plasma-cell infiltrate.


#microbiology #dermpath #RareInfection
Malignant #syphilis:
- uncommon form of secondary syphilis
- primarily affects immunocompromised persons.
-skin manifestations are varied, ranging from ulceronodular lesions to oyster shell–like crusts

#primarycare #MedTwitter #Awareness
Read 4 tweets
Let's go back to the basics. Syphilis is from an infection by the bacterium Treponema pallidum. Usually spread by sexual means, syphilis has three main stages of disease.

Primary infection usually presents as a papule that turns into a painless ulcer called a chancre.
2/ Image
Time from inoculation to chancre usually is 10-90 days (21 days is most typical).

There is a rare variant where the patient can get many smaller ulcerations, which is called Follman balanitis.
3/ Image
Read 16 tweets
A 31-YO♂️, #sexually active with 2♂️partners in the previous month: 8 days before redness of the R eye, an itchy perianal rash & rectal pain; scattered, tender, shallow ulcers & pustules on chest (A), abdomen (B), back (C) & perianal (D)
#proctology Image
PCR from the perianal vesicel:➕for nonvariola orthopoxvirus DNA.
Species-specific PCR: ➕for #mpox virus, clade II.

The patient reported a new rash with numerous ulcer on his chest, abdomen, and back

MPOX (formerly known as #monkeypox)

#MolBiol #virology
During the next 2 days, the patient took tecovirimat & reported redness & discomfort of the right eye and become painful

He had learned that mpox had been diagnosed in one of his #sexual partners from the previous month.


#ophthalmology #IDtwitter On examination of the right...
Read 9 tweets
We were consulted for a 2nd opinion.
30F. D1. Deep dog bite L cheek while tending fields. Multiple others bitten. Dog was killed the same day by villagers. #NeuroTwitter #MedTwitter #IDtwitter #NeuroRad #Neurology Image
D2. Visited PHC.
Prescribed PVRV (Abhayrab) D2, D5, D8, D13. NO RIG given. Image
D16. Fever, uncontrolled vomiting.
D20: admitted. Rx as sepsis.
D22 discharged. No hydro/aerophobia.
D23. Drowsy/unresponsive/taking orally food/water. Readmitted.
NB: Aerophobia is seen in ~50%, Hydrophobia in 10-15% Image
Read 11 tweets
1/ One of the privileges and duties of becoming a full professor is to write letters of evaluation for junior faculty in the promotions process at outside institutions. I give these a lot of thought and have completed 6-8 per year in the past three years.
2/ Usually, I receive an e-mail inquiry from an outside departmental administrator. When I agree to the evaluation, I am sent a promotion package prepared by the faculty member as well as a letter/document with promotions criteria by the host institution.
3/ I am increasingly troubled by requests for comparative evaluations:

Here's an example from one request letter (redactions to maintain anonymity):

• Estimate their (Dr. X's) standing in the field and compare them with other faculty of roughly the same cohort.
Read 18 tweets
I am going to write part of my (unfinished) story about the K to R transition as a woman in medicine and physician scientist in a multi-disciplinary research space in a tumultuous time. I am oversharing to encourage others in a similar 🚤#medtwitter #IDTwitter #AIMedEd. /1 of 20
I study #drug #allergy. It was the inferior antibiotic choices we made for people with vague antibiotic allergies during my residency @MGHMedicine @mghmedres that initially gave me the idea. Too often the allergy lists were impeding clinical care. /2 of 20
I hypothesized that drug allergies were a problem -- that penicillin allergies alone were linked to important antibiotic stewardship and public health outcomes. I set off to prove this, and address the burden of unclear drug allergies across populations. /3 of 20
Read 21 tweets
An 85-YO in rural Mississippi: months of tender, erythematous plaques & edema on bilateral hands extending to the elbows & on feet extending below the knees with significant pain

🔬skin granulomatous inflammation & numerous AFB

#IDtwitter #dermatology ImageImage
A repeat skin extensive granulomatous inflammation (A), with Ziehl-Neelsen stain clusters of acid-fast bacilli throughout the dermis (B).
Kinyoun stain >9 AFB/high-power field (C & D).

#dermpath #microbiology (A) Skin biopsy specimen, h...
Molecular identification: 100% identity to multiple Mycobacterium leprae


#MedTwitter #MolBiol
Read 19 tweets
Another gem from IDWeek 2022

Increased incidence of colorectal cancer in Veteran Health Administration hospital patients with pyogenic liver abscess

The rationale and the lit review
Read 10 tweets
Just got done presenting at the 31st Annual Clinical Update in Geriatric Medicine, put on by @AHNtoday and @UPMC. Awesome attendees, as usual!

Was asked to talk about "Controversies in Antimicrobial Therapy"

Figured would share here.

#IDTwitter #MedTwitter


With a Geriatric audience, had to take the opportunity to focus first on the urine.

But also get into SSTI, Bactrim for Group A strep, if you need IV antibiotics for Lyme, dental prophylaxis for prosthetic joints, and duration of therapy.

First up - does +UA/UCx=UTI?

Emphatic NO on that one.

Need SYMPTOMS to diagnose a UTI.

I tell patients they need to tell us, we can't tell them.

Positive UCx without symptoms = asymptomatic bacteriuria.

Read 38 tweets
An otherwise healthy 8 yr girl presents with a 2wk h/o asympt skin eruption. A wk before the onset, she had experienced mild fever, sore throat, & coryza for which she received symp Tx without any significant sequelae.
Guess what folks..!
#MedTwitter #idtwitter #MedEd #FOAMed ImageImageImageImage
-A h/o similar complaints was also elicited in some of her school friends
-The lesions were not associated with any atopic diathesis, preceding inflammatory dermatoses, drug intake, or suggestive systemic finding.
-O/E, multiple discrete hypopigmented macules & patches of varying sizes (0.5-1.5 cm) without any surface change were seen to be distributed symmetrically involving the dorsal & ventral aspects of bilateral lower limbs
Read 10 tweets
#Paxlovid effect on reducing #COVID19 hospitalizations in vaccinated population finally revealed to the public by FDA. #IDTwitter
0.9% (3/317) paxlovid vs. 2.2% (7/314) placebo…
The relative risk reduction (RRR) of #covid19-related hospitalization was 57.5% (95%CI, -63% to 89%) with #Paxlovid in vaccinated high risk population.

Will point out that the the Hazard Ratio is also 58% for $1 of #metformin.
If one combines the EPIC-SR vaccinated + EPIC-HR seropositive groups together, then risk of #covid19 hospitalization was:
▪️ 0.5% (4/807) with #paxlovid
▪️ 1.9% (15/791) with placebo
Relative RIsk Reduction = 74% (95%CI, 22%-91%)
Number Needed to Treat = 71 (95%CI, 40-300)
Read 27 tweets
Some very interesting dev in the Tx regimens for #TB especially the common rifampicin susceptible TB
#MedTwitter #idtwitter
The imp points 👇 Image
There were 4strategy groups with diff initial regimens; noninferiority was assessed in the 2 strategy groups with complete enrollment, which had initial regimens of high-dose RIF–linezolid & bedaquiline–linezolid (each with INH, PZA,& ETH).
-The primary outcome was a composite of death, ongoing treatment, or active disease at week 96.
Read 7 tweets
💥CLSI M100 33rd Edition
Updates 👇 - A thread 🧵
#MicroRounds #IDtwitter

Breakpoints for gentamicin, tobramycin, and amikacin are based on population distributions of various species, PK/PD target attainment analyses with an end point of net bacterial stasis and limited clinical data.
Clinical outcomes data for aminoglycosides as MONOtherapy for systemic infections are limited and have resulted in worse treatment outcomes (for infections outside of the urinary tract) compared with other therapies.
Read 22 tweets
A 44-YO♂️, stayed in a rural cottage of France 2 weeks previously: cramping upper abdominal pain with watery diarrhea.
He had passed what he thought were worms in his feces
#GITwitter #IDtwitter #microbiology “Worm” specimen brought to clinic by patient (petri dish
The specimens: identified as the larvae of the drone fly, Eristalis tenax
These larvae are 2.5–3 cm in length; the posterior tube gives them the name of “rat-tailed maggots”

#parasites #GIPath #Doctor “Worm” specimen brought to clinic by patient (petri dish
Myiasis caused by E. tenax:
✔️rare but have been
✔️reported from various countries including Europe
✔️most often intestinal myiasis, but cases of infestation of the nasal cavity, urinary tract, and vagina have been described.

#Doctor #MedStudentTwitter
Read 6 tweets
3 años ♀️, padre con lesiones cutáneas similares: lesiones cutáneas polimorfas localizadas en los glúteos, con elementos papulares, vesiculares y pustulosos umbilicados

🖊️M Roguera y col. @hgermanstrias @aepediatria
DOI: 10.1016/j.anpedi.2022.09.006
#pediatria #infecciosas Lesiones cutáneas en glúteo izquierdo. Detalle de las lesi
@hgermanstrias @aepediatria Se confirmó en el padre la infección por virus de la viruela del mono (MPXV).

PCR de líquido vesicular de las lesiones:➕para MPXV.


#MolBiol #virology #virología
@hgermanstrias @aepediatria Se realizó aislamiento de contacto y secreciones respiratorias (aérea y gotas) en el domicilio hasta la curación completa de las lesiones cutáneas (a los 10 días de evolución).
No hubo complicaciones ni nuevas lesiones en el seguimiento.

#IDtwitter #microbiología
Read 12 tweets
A 26-YO♂️ no #sexual contacts other than with his male partner: 6-day of fever, malaise, a swollen parotid gland, & ulcerative lesion on the ipsilateral lower lip.

Mild lymphopenia

#IDtwitter #dermatology #EarNoseThroat Swelling of left parotid gland (A)  The ulcerative lesion on
PCRs on the throat & ulcer swabs:➕for human #monkeypox (hMPX)
Genomic sequencing: clade IIb variant clustering within the current international mpox virus outbreak


#sexually #maxillofacial #microbiology
7 days after initial presentation, his clinical condition had improved together with a decrease in the parotid swelling and the size of the ulcer.

#MedTwitter #Doctor #MedStudentTwitter
Read 6 tweets
A 58-YO♂️, DM, fever & L lower quadrant abdominal pain 2 months prior: acute R-sided back pain, & 3/6 diastolic murmur at R upper sternal border.

CT: a R renal infarction & splenic embolism

MR: multiple infarctions
#Cardiology #medicine #cardiologia Enhanced abdominal computed tomography showing right renal i
Transesophageal echocardiography: a vegetation and severe aortic regurgitation.

Blood 🧫: Cardiobacterium hominis


#IDtwitter #microbiology Transesophageal echocardiogram revealing a large vegetation
The patient received antibiotic therapy and surgical aortic valve replacement, and he was doing well without major complications.

#infecciosas #MedTwitter #Doctor
Read 7 tweets
A 71-YO therapy for multiple mieloma, voriconazole for Aspergillus fumigatus sinusitis, prophylaxis with TMP-SMX: febrile neutropenia, nodular lesion on abdominal wall
CT: pulmonary nodule unchanged in last a month
🔬biopsy of pulmonary nodule?

#Pathologists #haematology Histopathology of the fine-...Image
🔬: Histiocytic process with granular basophilic cytoplasm and Michaelis-Gutmann bodies (arrows), positive for calcium with von Kossa special stain (arrowhead); findings pathognomonic for malakoplakia.

🧫of the pulmonary nodule:➖
🧫biopsy of the abdominal wall lesion: Rhodococcus equi resistant to TMP-SMX, but susceptible to rifampicin, vancomycin, azithromycin, ciprofloxacin, & imipenem.
Read 8 tweets
A 57-YO Mexican♀️, works on a farm has several pets, including dogs, at home: epigastric fullness, and a 15-pound weight loss.

CT: complex cystic left liver mass.
#gastroenterology #radiology #medicine
Resection: Cyst wall (red➡️), daughter cysts (*) normal liver tissue (yellow⬅️)
🔬acellular laminated wall (*), inner germinal layer (black⬅️), & protoscoleces surrounded by a broad capsule (green⬅️). Refractile hooklets (blue⬅️) & calcareous bodies (red⬅️)
#GIPath #IDtwitter

The patient underwent total excision of the cyst followed by albendazole therapy for 4 weeks.

#microbiology #GITwitter #MedStudentTwitter
Read 5 tweets
A 50-YO ♀️ bitten by her pet rat: fever, myalgia, sore throat, headaches a nonpruritic rash on extremities including palms & soles, arthralgias, knees arthritis.

A punctate wound with central necrosis on L palm, & her R thumb.

#rheumatology #internalmedicine #dermatology
Leukocytosis with neutrophilia
ESR & PCR:⬆️

Purulent R knee synovial fluid:
✔️46 000 cells/mL (88% neutrophils).
✔️Gram stain: scant pleomorphic gram-negative bacilli in chains with lateral bulbar swellings
#microbiology #rheumatologist
Synovial fluid 🧫culture: Streptobacillus moniliformis identified by biochemical testing & confirmed by MALDI-TOF.


#bacteriology #IDtwitter #microbiología
Read 9 tweets
A 17-YO♀️, unprotected #sexual intercourse with multiple male partners: a 1-month history of pruritic genital lesions, multiple smooth, grayish-white papules & plaques were noted on the vulva & upper inner thighs.

DOI: 10.1056/NEJMicm2207538
#gynecology #womenshealth Image
A Treponema pallidum particle agglutination assay:➕
Rapid plasma reagin titer: ➕1:16.


#microbiology #gynecologist #primarycare
✔️Testing for other sexually transmitted infections, including HIV infection: ➖

✔️Counseling on the importance of condom use

✔️IM penicillin G benzathine
At the 1-month follow-up visit, the lesions had resolved, and the RPR was 1:8.

#dermtwitter #IDtwitter #MedTwitter
Read 5 tweets

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