Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha

Chat recap of the #ClinicalPearls #VirtualMorningReport

July 22nd Day 98: clinicalproblemsolving.com/morning-report…
w/ @sargsyanz @StephVSherman @TheRealDSrini AVi Sonnenschei & Sara Torres

Let’s start with an initial problem representation:

A 31 yo M p/w 6 months of hematochezia, morning stiffness, diffuse symmetrical joint pains, & intermittent finger duskiness

intermittent duskiness? is this Raynaud's?

The overlap between GI and arthritis triggers spondyloarthopathies

BRBPR= lower GI bleed. Think colon masses/polyps, sigmoid diverticulosis (uncommon at this age but possible), anorectal disease (masses, hemorrhoids)

Adding onto the BRBPR: would be helpful to know how much blood. Is it only with BMs? only on TP/with wiping?

He takes naproxen? naproxen can trigger some lower GI bleeds ( diverticular bleeds) in addition to PUD

Any travel? thinking about Whipple’s

Are there any Mouth lesions? Or genital lesions?

want to sort out arthralgia vs. arthritis - redness/warmth/swelling/tenderness

this could be PAN as it causes GI bleed, arthritis and vascular phenomena in medium sized vessels, ncbi.nlm.nih.gov/books/NBK48215…

Add to his PR OCD, FMH history of Crohns, substance use disorder (IV meth), taking Truvada for PEP, and is sexually active with men only

Now more interested in the rectal exam - looking for local trauma, condyloma

Need an RPR and VDRL

likelihood of active HIV is low if on PEP

We are struggling with the posible Raynaud. Is it from cold agglutinins from a systemic disease or from his IV Drug use?

disseminated gonococcus with initial proctitis or
Lymphogranuloma venereum proctitis causing the rectal bleeding, ncbi.nlm.nih.gov/pmc/articles/P…

Here is another article on LGV: diagnostic and treatment challenges, ncbi.nlm.nih.gov/pmc/articles/P…

NAATs can be used to test genital lesions, as well as rectal, pharyngeal, & lymph node specimens for C. trachomatis.

Additional testing is needed to differentiate LGV from non-LGV

Now with some labs: Nml WBC, plts but mild anemia, normal liver function tests, mildly low lab w/nml Gamma gap, & neg HIV.

Not that helpful

We need viral serologies (viruses that cause polyarthritis) HCV, HBV, parvo

Also add autoimmune workup ANA antidsDNA, RF, anti-CCP

A little signal for inflammation as we already suspected given mild normocytic anemia (anemia chronic disease) and low albumin (anti acute phase reactant)

Some more data: RF, anti CCP, and ANA are neg
GC (-), Hep B (-), Hep C ab (+) but viral load (-), RPR (-) but FTA ab (+)

Remember for syphillis there are 2 types of serologic tests: nontreponemal tests and treponemal-specific tests.

The use of only one test is insufficient for diagnosis since serologic testing (especially nontreponemal tests) can be associated with false positive results.

Nontreponemal tests are RPR, VDRL, TRUST

are semi-quantitative in that the amount of antibody present (both IgM and IgG) generally reflects the activity of the infection

Approximately 20 to 30 percent have a nonreactive nontreponemal test

Treponemal tests have historically been more complex and expensive to perform than nontreponemal tests.

These include Fluorescent treponemal antibody absorption (FTA-ABS), (MHA-TP), (TPPA), (TP-EIA), (CIA)

Detection of abs directed against specific treponemal antigens

Once a patient has a positive treponemal test, this test usually remains positive for life.

Add to PR FOBT + for stool and WBC along with fecal calprotectin of 1,831 (N= <120)

Nml xrays of joints: RUQ US showing a hyperechoic left hepatic lobe lesion, mild splenomegaly

Is this e histolytica?

interesting that it’s in the L lobe given blood flow to the liver as 50% of solitary liver abscesses occur in the R lobe (a more significant part with more blood supply), less commonly in the left liver lobe or caudate lobe.

ncbi.nlm.nih.gov/books/NBK53823….

Is this tertiary syphilis in liver eroding into lower colon somewhere w/ destructive gumma?ncbi.nlm.nih.gov/pmc/articles/P…

And now a colonoscopy that shows active colitis that's stains w/ Warthin Starry + for intestinal spirochetosis

And the final dx is straight of left field.....Brachyspira

Tx with metronidazole

Don't worry, we all need a review on Brachyspira
ncbi.nlm.nih.gov/pmc/articles/P…

Human intestinal spirochetosis – a review, https://t.co/oEYXx65CR9

The liver lesion is likely an Incidentaloma

The arthritis was felt to be reactive

Great case @TheRealDSrini

Teaching points overview by @sukritibanthiya

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