Thread by @RosenelliEM

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

Chat recap of the #ClinicalPearls #VirtualMorningReport

July 31st Episode 105: clinicalproblemsolving.com/morning-report…

case presenter @Rafameed

Let’s start with a problem representation:

A 42 y/o M w/ no PMH presents with confusion and syncope but prior to this he noted 4 months of worsening cervical LAD and oral ulcerations along with a 5kg weightloss, cough, SOB w/ exertion & voice changes

cervical adenopathy & oral ulcerations, hm

are these painful? mobile?

oral ulceration, makes us think fungal, sarcoid, &autoimmune as well

This could be TB (scrofula) or “king’s evil”, royal touch was believed to cure the disease until the 18th cent ncbi.nlm.nih.gov/pmc/articles/P…

Head and neck cancer can cause ulcerations and metastasize to neck. Then secrete PTHrp and cause hyperCa which can cause confusion

Plugging in his symptoms into Isabel (isabelhealthcare.com) Kikuchi disease was red flagged (a @rabihmgeha favorite)

also SLE, TB, PJP, AML, sarcoidosis, histo, erdheim chester get some interest

SLE can cause nonpainful mouth ulcerations, ncbi.nlm.nih.gov/pmc/articles/P…

What about syphilis? usually lesions are painless, but can be painful as well and causes vascular lesions.

This patient has at least 8 clinical problems: altered MS; transient LoC; large LN; IWL; dyspnea; cough; voice change; and N&V

Hard to know what to prioritize without getting lost in noise

Now some PE findings: He is febrile, bradycardia, hypotensive

Also add oral mucosal hyperpigmentation

Makes us wonder about adrenal insufficiency

Adrenal insufficiency would go nicely with disseminated TB or anything else fungal ncbi.nlm.nih.gov/books/NBK27908…

Bradycardia could be present in increased intracranial pressure

What if proximal pacemakers are being infiltrated by ___?

there appears to be a sign of an intracellular bacterial infection

Why does he have severe abdominal pain? If he has hypercalcemia this could explain. Also the syndrome of adrenal crisis can include quite severe abdominal pain

Labs showing a nml WBC with eosinophilia, anemia, hyponatremia, hyperkalemia, renal failure, hypercalcemia

His assoc low albumin also increases his already elevated Ca from 10.5 mdcalc.com/calcium-correc…

adrenal insufficiency can cause eosinophilia as corticosteroids exert eosinopenic effects, at least in part, by stimulating eosinophil apoptosis.
e-journal.gr/en/eosinophili…

With a Cr of 9 he needs an ECG, IV Glucose, IV insulin, IV hydrocortisone 50-100mg, 📞neph, 20mg of albuterol nebs, IV calcium gluconate 1-2 g q 5 min until ECG normalizes

ncbi.nlm.nih.gov/pmc/articles/P…

infectious causes of AIL tuberculosis, histoplasmosis, cryptococcosis, paracoccidioidomycosis and CMV infection

Distal tubule is where aldosterone works; if adrenal insufficiency is present, low in aldosterone

A great AI illness script: @AnnKumfer

Maybe a granuloma on the vocal cords explains his hoarsness

Bilateral mets is a really rare cause of AI even in people with cancer w/ adrenal mets. pubmed.ncbi.nlm.nih.gov/11849252/

Have to have tumor taking up 90% of gland prior to getting symptoms.

@Rafameed is a master storyteller

Add to history that the patient is a cattle farmer and in Brazil this makes us think about a few things like M Bovis, non-TB mycobacterial infection

ppd could be negative in miliary
igra could be negative in active tb

we need to sample a lymph node

And the final dx is Paracoccidioidomycosis which is an acute - to chronic systemic mycosis caused by fungi of the genus Paracoccidioides.

ncbi.nlm.nih.gov/pmc/articles/P…

ncbi.nlm.nih.gov/pmc/articles/P…

Teaching points illustration by Sukriti Banthiya @sukritibanthiya

Some more about Paracoccidioides

The genus Paracoccidioides belongs to Phylum Ascomicota, Class Euromycetes, Order Onygenales and Family Ajellomycetaceae (Onygenaceae), the same as Histoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immites and Coccidioides posadasii,

It occurs more frequently in its chronic form, which particularly affects male adults from rural areas.

These patients present w/ pulm involvement & systemic symptoms.

The involvement of the upper airway mucosa is common & pts usually complain of dysphagia and dysphonia.

Subclinical disease, detected by skin tests with paracoccidioidin antigen, occurs in up to 60% of the population in endemic areas

Overall, it is est that 10% of the pop in endemic countries are infected

Tx requires long-term antifungal sulfonamides, amphotericin B, & imidazoles

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