Time for some #SpacedRepetition: @CPSolvers
Chat recap of the #ClinicalPearls #VirtualMorningReport
June 11th Day 70: clinicalproblemsolving.com/morning-report…
w/ @Kaitlyn_Rogers9 @DxRxEdu @rabihmgeha @medrachel
Teaching points clinicalproblemsolving.com/wp-content/upl…
Before we begin, some great articles were shared regarding our current our pursuit for #Equality
huffpost.com/entry/black-me…
Forbes “Dear White People: Here Are 10 Actions You Can Take ….” #1 – Get to Know More People of Color…#10 – Speak up publicly forbes.com/sites/danabrow…
Let's start with a problem representation:
A 74 yo M with a PMH of myelofibrosis not currently under therapy and recently treated for CAP presents from his pulm clinic w/ SOB, recurrent fevers, and GERD like sxms found to have a recurrent infiltrate on Xray.
The first question is this another "CAP"
Is the patient on a JAK inhibitor? is patient pancytopenic?
That really impacts the ddx
We all wish we knew about Myleofibrosis..
A thread about the confusing "myelo" nomenclature by @DavidSteensma,
Myelo- comes from ancient Greek,in which the same word μυελός (myelos) was used to describe three things: bone marrow, the spinal cord, and, to a lesser extent, the brain.
Why the same word for these unconnected organs/tissues, Dr. Hippocrates?
I would assume immunocompromised host until prove otherwise
is this primary or secondary myelofibrosis as PV could lead to MF.
with MF I imagine cytopenias and a big spleen (sometimes a big liver)
Anyone familiar with Wacker’s triad? A Triad for the Diagnosis of Pulmonary Embolism and Infarction from 1961.
Serial measurements of the serum LDH, SGOT (serum glutamic oxalacetic transaminase) activity, & serum bilirubin concentration. jamanetwork.com/journals/jama/…
Has anyone seen Dr. Redelmeier’s essay about why we should no longer teach triads? onlinelibrary.wiley.com/doi/abs/10.111…
Back to this "infiltrate" is the infiltrate in the lung infectious/inflammatory noninfectious or something else (cells?)
A good 2 view (PA & LAT) can really help
Cool genetics of MPN: JAK2 > CALR & MPL, although plenty of other genes can be mutated, and a subset are “triple-negative”
ALR is an ER chaperone protein, & MPL is the TPO receptor,which makes total sense for a MPN!
typical tx for primary MF=ruxolitinib, ncbi.nlm.nih.gov/pmc/articles/P…
it's never a "CAP" until treated as CAP
pulmonary extramedullary hematopoiesis (EMH) can do this — thorax.bmj.com/content/68/2/1…
Rigors are actually a good predictor of bacterial infection
@haematognomist MPN pearls, in this case for Polycythemia Vera. The CYTO-PV trial showed that “among patients with JAK2-positive polycythemia vera (PV), maintaining a target hct of <45% has a🔽rate of fatal & non-fatal cardiovascular or thrombotic events vs hct of 45-50%.”
Since pt was on ruxolitinib it created some chat
The most frequent infections on jak inhibitors per case reports, were tb (N = 10), hep B reactivation (N = 5) & PJP infection (N = 2). pubmed.ncbi.nlm.nih.gov/29150886/
baricitinib is a new jak inh tested in COVID, contagionlive.com/news/arguing-t…
JAK2 inhibitors do not affect stem ... the spleen shrinks bc MF progenitor cells undergo apoptosis ashpublications.org/blood/article/…
Recent trial for ruxolitinib being used for GVHD
nejm.org/doi/10.1056/NE…
The pt is a plumber and works under houses, we are all having 🐀 nightmares
His work history opens theories of fungal infections in NC. Histo? Blasto?
CD doesn’t list any reportable fungal diseases for NC, cdc.gov/fungal/fungal-…
Histo map,images.app.goo.gl/duZ5v11cFhZ2vt…
usually aspergillosis requires pretty bad neutrophils not working, aspergillus.org.uk/content/neutro…
Cool peripheral smear that can be seen in the setting of fibrosis is the “teardrop” cells
Plumbers associated with asbestos glioblastoma bc of the glue they use, ncbi.nlm.nih.gov/pmc/articles/P…
Throwing someone on a fluoroquinolone first line for cap just grinds some of our gears
"antibiotic refractory pulmonary syndrome" a new fun term
Could this be TB? linezolid, quinolones and macrolides treat TB and could have been given for CAP.
Ruxolitinib discontinuation can cause ARDS — researchgate.net/publication/26…
For someone with an established condition, now w/ new illness:
1. Is it a flare of that disease (ds)?
2. Is it a complication of that ds?
3. Is it a complication of the tx for that ds?
4. Is it something entirely new?
And infiltrates could be non-expectorated alveolar blood
Intermittent hemoptysis without progressive lung disease also makes me think of HF & lung AVMs
Inhibition of JAK-STAT signaling pathway by Ruxolitinib results in a dramatic🔽in levels of inflammatory cytokines, such as IL-6 & TNF-α.
maybe increased risk of TB w/ tnf being low?
Faget’s sign -have learned to reflexively look at at med list
Big spleen, lung infiltrate, fingernail bruise. hmm..
is it a splinter hemorrhage?
disseminated fungi like Fusarium, blasto, candida can be at play here
i still think we need a ct and bal/biopsy
Hantavirus would usually have elevated hematocrit + bandemia + atypical lymphs,, cdc.gov/hantavirus/tec…
Invasive Fungal Disease After Remote Inoculation in Transplant Recipients,
pubmed.ncbi.nlm.nih.gov/21148507/
Most common rhythm in pe is ST, 10%–25% of patients with PE have a normal ECG.
A true left shift is when there are bands
Biatriospora mackinnonii infection, a form of phaeohyphomycosis. Think brown-pigmented (dematiaceous) molds, which can often get inoculated thru trauma
We cannot memorize everything but know that it occurs will prompt us to look it up
His chronic ppi leading to him to be predisposed to something? This study found the risk of pneumonia increased by 55% in patients who were taking PPIs ncbi.nlm.nih.gov/pmc/articles/P….
ICU patients using pump inhibitors have a three-fold increased risk of developing VAP vs H2-blocker receivers, ncbi.nlm.nih.gov/pmc/articles/P…
He drinks alcohol daily & has posterior infiltrate: Could be aspiration
Is this Drug induced penumonitits, pneumotox.com/drug/view/653/…
Pigeon droppings appear to be the most important source of the disease fungus Cryptococcus neoformans in the environment,
HEALTH HAZARDS ASSOCIATED WITH BIRD AND BAT DROPPINGS, idph.state.il.us/public/hb/hbb&…
Recurrent pneumonia different from non-resolving pneumonia….recurrent pneumonias resolve then come back….most common cause of recurrent pneumonia is aspiration
Final dx: Recurrent aspiration w/ pneumonitis related bleeding
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