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❓Can you differentiate between the 3 most common types of amebic encephalitis… follow the 🧵

1️⃣ Naegleria fowleri:

📍- 🌎wide. In warm water & soil
👇🏼
Trophozoites ➡️👃🏼➡️ olfactory nerves ➡️ 🧠

🔎- primary amebic meningioencephalitis -
⚡️incubation ⏲ - 5 days
⚡️fatal
🧪- ⬆️ ICP w/ ⬇️glucose, ⬆️protein & RBCs

🔬- motile trophozoites can be see in CSF wet mount,
brain biopsy (no cysts will be seen)

2️⃣ Acanthamoeba spp.

📍- 🌎wide. In fresh water, brackish water, HVAC, & soil

🔎
Keratitis - contact lens
Cutaneous - papules ➡️ ulcer
Read 8 tweets
1/14
Hey #MedTwitter!

Ever question the utility of asymptomatic urine testing in delirious, older patients?

Passionate about avoiding low-value tests that may harm vulnerable patients?

If so, please join us on this Tweetorial journey based on our @JHospMedicine @TWDFNR piece! Image
2/14
Let's start off by getting a sense of how everyone approaches this clinical situation.

In the work-up of delirium in an older adult, which of the following groups would benefit from urine testing?
3/14
Some background on delirium's impact:

This @jama study (Oh et al, pubmed.ncbi.nlm.nih.gov/28973626/) states that in US alone, more than 2.6 million adults 65 years and older each year develop delirium, accounting for an estimated $38-$152 billion in annual healthcare expenditures!
Read 16 tweets
#IDBoardPearls #IDtwitter #IDPhotoQuiz

📟 54 YO M with type II diabetes presents with a mobile, nontender node on the left side of his neck.

Biopsy culture: Journal of clinical and diagnostic research
❓Clinical presentation & micro is consistent with what infection?
Answer: Actinomyces spp

🎙Cervicofacial Actinomycosis:

Risk factors - diabetes, trauma, 🦷 infections

🧫- “sulfur granules,” molar 🦷 appearing colonies on plates
👇🏼
vs Nocardia’s chalky white ➡️ orange color
Read 7 tweets
1/ Transplant patients have significantly reduced antibody responses to #COVID vaccination. But does that matter? This report shows that it does. SOT recipients have a 82-fold higher risk of #breakthrough infection compared to immunocompetent hosts.

journals.lww.com/transplantjour…
2/ Even more important, serious consequences of #breakthrough infection are even more common in SOT receipts. They have a 485-fold higher risk of breakthrough infections that lead to hospitalization or death.
3/ Reporting the results as cases per million vaccinated puts this into perspective. For example, the CDC reported that a little more than 1 in 1 million normal hosts (immunocompetent ppl) will die from COVID following vaccination. For transom at recipients, that number is 664. Image
Read 10 tweets
#IDBoardPearls #IDtwitter #IDPhotoQuiz

📟 A farmer from the Dominican Republic is here in the US visiting family & presents with a swollen foot that has been progressing over the past 8 years

📸 of his R foot along with biopsy of lesion Indian Journal of Surgery S...University of Adelaide
❓What is the mostly likely organism?
Answer: Madurella mycetomatis

🎙Cutaneous Fungal/Mold Infections:

🚨Madurella mycetomatis: Eumycetoma or “Madura foot”
🔎- traumatic inoculation ➡️ chronic nodular lesions w/ sinus tracts w/ macroscopic grains ➡️ 🦴 Evolve over yrs
🔬- grain w/ numerous hyphae
👇🏼
This is fungal
Read 13 tweets
#IDTwitter

DarcyDoesC.diff

Or #Cdiff pearls

Or how I approach C. diff in light of new guidelines
PCR tests are very sensitive but specificity stinks

Be sure of appropriate clinical context (true diarrhea, diarrhea not due to another cause) before testing.
Initial tx with PO Vanco. Guidelines prefer fidaxomicin but too expensive. Reserve fidax for highest risk (SOT, BMT).
Read 9 tweets
US nationwide outpatient trial for early #COVID19 using existing, repurposed medicines. ACTIV-6 trial is sponsored by US gov @NIH. Participate from home. No travel required. Please spread the word. Info at combatcovid.hhs.gov/joinaclinicalt…
There are a number of medicines being tested:
-Ivermectin
-fluvoxamine (luvox)
-inhaled fluticosone (flovent)
All of which have various degrees of promising data.

ACTIV-6 study is seeking to answer:
1) do these make people feel better faster?
2) do they prevent hospitalization?
The initial @NIHDirector press release on activ-6 trial explains some of the objectives and big picture activities of this outpatient trial. #IDTwitter #MedTwitter nih.gov/news-events/ne…
Read 9 tweets
1/ #IDTwitter #HIVTwitter

Today we will review some of the common types of #HIVDrugResistance tests. Image
2/ I first break down testing into 2 broad categories of resistance tests: Image
3/ There are 2 major types of genotype tests that we use to detect #HIVDrugResistance Image
Read 17 tweets
#idboardreview heart-lung transplant 2yrs ago on tacrolimus, mycophenolate, TMP/SMX, lung nodules on voriconazole, +diffuse body aches, AlkP 2x ULN, Bone scan numerous scattered areas of uptake. Xray periosteal thickening, Calcified excrescences. dx? #medEd #idmedEd #idtwitter
#Voriconazole SE vision changes, rash, nausea, vomiting, abnormal liver function tests, hallucinations
#Periostitis w/ long term voriconazole diffuse body aches, ,inc AlkP patches of periosteal thickening on Xray &+bone scan. Calcified excrescences are sometimes seen.
Read 7 tweets
1/ #IDTwitter #HIVTwitter #HIVDrugResistance

To keep the momentum going, let’s move on to transmitted drug resistance. For those just joining, we previously discussed that #HIVDrugResistance is important yet challenging for learners.
2/ We also reviewed the basic principle that HIV resistance develops when HIV replicates in the setting of subtherapeutic drug levels. Virions containing resistance mutations are selected for in this case.
3/ Today we’ll define transmitted drug resistance (TDR) (vs acquired drug resistance). TDR = acquisition of drug-resistant HIV at the time of new HIV infection. We identify TDR when we do a baseline HIV genotype (recommended for all patients who are newly diagnosed with HIV).
Read 12 tweets
#idboardreview A businessman develops diarrhea while traveling to Thailand.The illness progresses to passage of grossly bloody stools. Sick x3d when returns home. +bloody stools, weak, febrile, tachycardic, stool:gull wing shaped GNR. Treatment? #medEd #idmedEd #idtwitter
Single dose of azithromycin (1 gram). Acute febrile & dysenteric diarrhea in single adult traveling to a developing region is most likely caused by strains of Shigella, #Campylobacter or Salmonella. Campylobacter shown here Ref pic casereports.bmj.com/content/2014/b…
Treatment of choice must be guided by antibiograms of likely organisms in geographic region where pathogen was acquired. In South Asia ciprofloxacin-resistant Campylobacter is most likely cause of febrile dysentery. Tinidazole is useful for giardiasis not Campylobacter diarrhea
Read 8 tweets
#idboardreveiw 45 F hx IUD w/ incarcerated, inguinal hernia. During surgery: hernial sac w/ putrid, inflammatory, tumorous formation around R ovary. Histopath highly active zone of abscess formation, w/ granular conglomerates of a filamentous organism. #idmedEd #medEd #idtwitter Image
#Actinomycetes anaerobic, gram+ filamentous bacteria sulfur granules in tissue & highly sensitive to penicillin. This pt needs tx as abscess but in general #Actinomyces normal GI flora & asymptomatic female genital colonization is not uncommon, especially if an IUD is in place
Read 5 tweets
#IDBoardPearls #IDtwitter

Derm round ✌🏼. Let’s do this…

Bacterial Skin Diseases. Follow the 🧶

1️⃣ Impetigo: superficial epidermis
🔎- vesicles/pustular ➡️ crust “🍯 yellow”
🦠- GAS, S aureus

‼️ S aureus causes bullous impetigo similar to poison ivy
❓What other skin manifestations does GAS cause? 👇🏼

2️⃣ Erysipelas: upper dermis and superficial lymphatics
🔎- acute, well-demarcated, 😣, erythematous lesion, 🤒
🦠- GAS, B hemolytic strep

3️⃣ Cellulitis: deeper dermis, subQ tissue
🔎- erythema, warmth, edema, not well-
demarcated
🦠- strep (GAS), S aureus

4️⃣ Necrotizing Fasciitis: muscle, fascia, & fat
🔎- initially spares skin, hence, pain out of proportion to PE ➡️ skin crepitus ➡️ discoloration ➡️ bullae ➡️ tissue necrosis ➡️ sepsis, HD instability
🦠- Type I: mixed aerobic & anaerobic
Read 14 tweets
#IDboardpearls #IDtwitter

Derm… ☠️ Let’s break it down starting with viral exanthems. Follow the 🧶

🚨Coxsackievirus:

1️⃣✋🏼,🦶🏼, & mouth disease - Coxsackie A > Coxsackie B or EV71
🔎 - 😣 ulcerative lesions on hard palate, 👅, buccal mucosa ➡️ vesicular rash on 🤲🏼 &🦶🏼
2️⃣ Atypical HFMD
🔎- vesiculobullous rash or crusted papules (Gianotti-Crosti syndrome). Associated with skin and 💅🏼 peeling. At sites of atopic eczema (eczema coxsackium)

🚨Parvovirus B19:

1️⃣ Erythema infectiosum - Fifth disease
🔎- 👋🏼 cheek syndrome ➡️ lacy erythematous
rash on truck & limbs

2️⃣ Papular-purpuric (🧤&🧦) syndrome
🔎- pruritic erythema & edema of distal limbs (sharp demarcation at wrists/ankles ➡️ petechial or purpuric

🚨Measles:

1️⃣ Measles exanthem
🔎- starts behind the 👂🏼then spreads to face, trunk, limbs (🤲🏼🦶🏼)

2️⃣ Atypical
Read 13 tweets
#IDBoardPearls #IDtwitter

Post-exposure prophylaxis. As with all things, timing maters 😷

1️⃣ HAV:
Indications - close contacts, child care & school contacts, food handlers
⏲ 2 weeks - 💉
👉🏼 + Ig if > 60 YO or immunocompromised
⏲ 28 days - 💉
👉🏼 + Ig if chronic liver disease
or Hep B/C infection
⏲ 8 weeks - 💉 if there are > 1 close contacts in 🏠

2️⃣ HBV:
Indications - percutaneous or mucosal exposure, sex or needling sharing contact, victim of sexual assault
⏲- within 24 hrs, up to 7 days

📌Unvaccinated 🧍🏻‍♀️+ source HBsAg + ➡️ 💉 + Ig
📌Vaccinated 🧍🏻‍♀️+ source HBsAg + ➡️ booster 💉
📌Unvaccinated 🧍🏻‍♀️+ source HBsAg - (or unknown) ➡️ 💉 series
📌Vaccinated 🧍🏻‍♀️+ HBsAg - (or unknown) ➡️ no treatment

3️⃣ VZV:
Indications - face to face contact or in a room for > 15 min with the following:
📌exposure to chickenpox or
Read 10 tweets
The arrival of new interns in July is an excellent opportunity for us to revisit the basics- today let’s talk about a test that is simultaneously one of the most overused and poorly interpreted tools in medicine: the UA.

Say it with me now… INFLAMMATION ≠ INFECTION

1/10
The UA is actually not one test but many! It can roughly be thought of in 3 separate parts: renal, metabolic, and inflammatory panels. Bundling these together can lead to diagnostic error and overtreatment of fake news “UTIs” that are not, in fact, infections.

2/
We prevent lots of harm to patients when we remember that UTI is a clinical diagnosis based on symptoms and not UA criteria.

So when ordering a UA for renal/metabolic reasons – tell yourself in advance:

INFLAMMATION = INFECTION
BACTERIA = INFECTION

3/
Read 12 tweets
#IDBoardPearls #IDtwitter

I get tripped up on these so let’s go over them… head/neck space infections 🤕

1️⃣ Peritonsillar abscess: “Quinsy”

📍- between the tonsil & the pharyngeal muscle
🦠- strep, staph, anaerobes
Clinical: swollen tonsils + uvula deviation, 🤤, trismus, 🤒
‼️ vs - Epiglottis, which has a normal pharyngeal exam. “Worst sore throat of my life” + hoarseness + 🤤
👇🏼

2️⃣ Epiglottis:
📍- invasive cellulitis of the epiglottis
🦠 - Hib (prior to 💉), sometimes no 🆔
Clinical - hoarseness (“muffled voice”), 🤤,🤒, 🍒red epiglottis, 👍🏼 print
sign on lateral xrays

‼️ attempt to use 👅depressor ➡️ 🆘 airway

‼️ vs - Croup. 👶🏻 less toxic, +coughing, no 🤤

3️⃣ Ludwig’s Angina:
📍- b/l floor of the mouth (sublingual + submylohyoid)
🦠- polymicrobial ➡️ 🦷 infection (2nd & 3rd molars)
Clinical -
Read 6 tweets
More 1st year ID fellow pearls #IDTwitter #MedTwitter- a chat about dx of cellulitis! Last week, we discussed two clinical trials for prevention of recurrence- today, lets discuss ALT70, a scoring system for dx. (1/8)
Most cellulitis is strep or staph and a lot of folks seem comfortable with its tx- IDSA guidelines are helpful, especially Figure 1: academic.oup.com/cid/article/59… (2/8)
However, there are many mimickers of cellulitis- "pseudocellulitis". In one retrospective study of a year of Dermatology consults, half of all consults were ordered for evaluation of cellulitis and only 25% of pts were found to have true cellulitis (pubmed.ncbi.nlm.nih.gov/26089048/) (3/8)
Read 8 tweets
1/ Happy Opportunistic Monday #IDtwitter #IDfellows; another interesting case and learning opportunity, written by @johnhannamd and @KrutiYagnikDO
2/ Following tissue diagnosis, what is the best next step in management?
3/ #IDpearls

Leading differential diagnosis of pulmonary infiltrates and skin lesions in HIV patients include:

Typical bacterial
TB, NTM
Cryptococcus, histoplasmosis, other dimorphic fungi
Lymphoma, KS
Read 17 tweets
Hi #IDTwitter and #MedTwitter! As we near the end of 1st year of ID fellowship @MGHBWHIDFellows , I wanted to reflect on 10 RCTs that I found useful on General ID. This is neither all-encompassing nor meant to get into the meat of study design/critique (#IDJournalClub). (1/12)
1. Staph aureus bacteremia (SAB) is our bread and butter! We are often asked about combination tx. DASH (pubmed.ncbi.nlm.nih.gov/29843781/) did not show benefit to adding daptomycin to beta-lactams for treatment of MSSA SAB. Duration of bacteremia was the primary endpoint. (2/12)
2. What about dreaded MRSA bacteremia? Likewise, CAMERA2 did not show benefit of combo tx w in MRSA SAB and had to be ended early due to AKI in the combo group (jamanetwork.com/journals/jama/…). Synergy with ceftaroline is an upcoming area (journals.asm.org/doi/full/10.11…) (3/12)
Read 12 tweets
Inspired by @PeterHotez #grandrounds, we started a pilot elective to teach #scicomm & debunking #misinformation to @uchipritzker medstudents

Each student selected a myth to debunk & created an infographic with science/#visualart guidance
#medtwitter #scienceupfirst 🧵
Inspired by @tropical_toxic cover art @TIME assignments, @sara_serritella and I are sharing their work here w/permission.
Students could choose any misinformation to debunk. While some chose COVID19, not all did! They also specified their audience.
2/x
For those skeptical of government creating vaccines by Zachary Newman MS1:

We have risen to the challenge before and accomplished amazing things through working together. The mRNA vaccines show us at our very best. #Getvaccinated #amazingthings #COVID19vaccine #thisisourshot 3/x
Read 17 tweets
1/ Happy Opportunistic Monday #IDtwitter #IDfellows! Here is another interesting learning case for you all. Written by @KrutiYagnikDO and @johnhannamd Image
2/ While awaiting pending work-up, what is the best next step?
3/ #IDpearls

Major differential in this newly diagnosed HIV patient, presenting with brain ring enhancing lesions:

-CNS toxoplasmosis
-Primary CNS lymphoma (usually EBV+)
-TB
-Cryptococcus
-brain abscess
-Nocardia
-Chagas (given visit to Peru)
-Malignancy
Read 15 tweets
1/ Hello #IDtwitter #IDfellows and Welcome to “Opportunistic Mondays”! For the next few Mondays, @KrutiYagnikDO and @johnhannamd will be presenting interesting OI cases with major teaching points. Enjoy!
2/ What is the drug of choice for his pneumonia?
3/ + HSV 2 swab from buttock lesion with lymphopenia should prompt HIV screening

HIV ab returned positive; HIV-1 with VL of 790k and CD4 of 10 (5%)

#IDpearls: Pneumocystis Pneumonia (PJP) is the most common respiratory OI in HIV with CD4<200, not on PPx.
Read 13 tweets
I often hear, and have felt myself like the need in India and South Asia is so great right now, but I didn’t know where my donation would be of the most use. While it is wonderful to donate to large international NGOs and other respected organizations, I wanted to feel like my /1
Donation would have an immediate impact for the people who need it the most. That’s why my family chose to set up a GoFundMe to support the hospital in Manali where we have volunteered over the past decade. While I had hoped the remote nature of the hospital would protect them /2
As expected, #COVID19 is flooding the Kullu Valley and surrounding regions. The hospital in Manali, LWH, is seeking supplies, PPE, and donations to continue to provide quality care while protecting the hospital staff (Image: Kullu Valley @anraed42 lnkd.in/daTwWKt) /3
Read 8 tweets

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