Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha @dminter89
Chat recap of the #ClinicalPearls #VirtualMorningReport

Episode 140 - Virtual Morning Report - September 11, 2020 clinicalproblemsolving.com/morning-report…

Let's start with an initial PR:

A 27 y/o male with no PMH from Mexico presents with 10 days of generalized abd pain, vomiting, diarrhea, fever, & yellowing of his eyes

Deploy our Jaundice Schema; clinicalproblemsolving.com/dx-schema-jaun…

Other causes of yellow skin, e.g. excess beta carotene, usually do not cause deposition in conjunctiva or sclera, so eyes aren’t yellow

sounds biliary in nature, but could also consider hemolysis with gallstones like in her spherocytosis or something like that.

PNH can cause mesenteric vein thrombosis causing abd pain & jaundice

definitely want to consider viral hepatitis, TB, leptospirosis. Want to know his immune status as well.

What about Vanishing Bile Duct Syndrome... Seen on the last @UnremarkableLab ncbi.nlm.nih.gov/books/NBK54871…

what about mosquito borne or rickettsial

other one would be hepatic amebiasis causing obstructive jaundice and abdominal pain

malaria also a consideration depending on location although not as endemic in Mexico.

typhoid fever as a consideration as well as Leishmaniasis

HIV test would be important. HIV cholangiopathy is common, caused by cryptosporidium, CMV, microsporidium

If he is drinking unpasteurized milk, can get Brucellosis,

Vitals show fever, appropriate tachycardia, nml BP

PE shows icterus, diffuse abd pain, hepatomegaly

Labs shows WBC: 14.7, Hgb 13.4, Plt 46,

Na 127, T Bili 13.7 D Bili 9.2, GGT 345, Alb 2.8, PTT ⏫⏫ 48 , INR 1.5 Lactate 3, Fibrinogen 595, ALT 108, AST 118

Hep A IgG + Hep serology neg

based on abdominal pain, jaundice, fever ill start treating for cholangitis, needs Zosyn

markedly elevated bilirubin compared to transaminase levels

schistosomiasis can cause portal hypertension leading to thrombocytopenia. can present with biphasic illness (Katayama fever)

I would start doxy. def worried about possible leptospirosis with hyperbili, hyponatremia, and thrombocytopenia

Is hyponatremia poor intake/losses/, adh elevation, disease mediated (like lepto/rickettsial), or adrenal

WE need some imaging

CT shows occluded mesenteric vein, heterogenous liver with periportal edema, non-occlusive portal vein thrombosis, appendicial inflammation with right sided colitis

MRCP confirms colitis with mesenteric and portal vein thrombosis. hmmmm

Fun fact: Leptospira inhibits the Na+-K+-Cl- cotransporter activity in the thick ascending limb of Henle, resulting in hypokalemia and sodium wasting which is why hyponatremia present

Stool cultures shows PCR + camplyobacter

Blood cultures return + for Ecoli and Strep Anginosus

Is this strongyloides? polymicrobial bacteremia

strongy is associated with polymicrobial infections and predisposing to bacterial infections including meningitis I think it is due to leaving GI tract letting bacteria to leak out.

htvl1 is also associated with strongy

Strep Anginosus is a "Honey Badger"

CIA strep causing abscesses (constellatus, intermedios, anginosus,

ncbi.nlm.nih.gov/pmc/articles/P…

you can get portal vein thrombosis also from GI infectious even diverticulitis, ncbi.nlm.nih.gov/pmc/articles/P…

A related NEJM case: Case 3-2020: A 44-Year-Old Man with Weight Loss, Diarrhea, and Abdominal Pain. nejm.org/doi/full/10.10….

Some more labs showing neg lupus anticoagulant but Positive Anti Beta 2 Glycoprotein that was confirmed a few months later. Final Dx

Antiphospholipid Syndrome causing a septic thrombophlebitis of mesenteric and portal vein

Lemierres cousin of the GI tract, can we name it? O’Donnell syndrome... Great case Matt!

A free read here. Gem by @Gurpreet2015 ncbi.nlm.nih.gov/pmc/articles/P…

Teaching points illustration by @sukritibanthiya

@GurleyGuy @AndreaAnampaG @AnthonyPensa @lakh_malla @PGuptaMD @YihanYangMD @DanielCLiauw @ASanchez_PS @AbelJosephMD @BrentChamMD @this_is_svenka @SurajNagaraj @dminter89 @Doc_Fomin @AnnKumfer @DoubleDawgMD @Anand_88_Patel @MikeRoseMDMPH @haematognomist

@Sharminzi @ArsalanMedEd @ecvasti @JonathanRyderMD @RezidentMD @GurleyGuy @appyjumpindaze @justalisongrace @DavidTHLam @BethGay45 @BrandonKinneman @rongejman @BryanCUlrich @victorekuta @DanaAmara1 @NishaSunkuMD @pri_athavale @BhavyaVarma12 @sargsyanz @StephVSherman

@noahrosenberg @JFBirnbaum @chioma_ndukweau @andressa__k @PeytonNesmith @blairgolden @BP76104 @Gurpreet2015 @mBohlega @INizamuddinMD @AlexHorneMD @EricaLCrosley @AJ_Kurtzman @miniisms @dsouzl @AaronLTroy @danielgauvin07 @AdamLongMD @d_dressler92 @Chris_Lees_

@tmodarressi @DanielleEngskow @AnneArnason @AmandaGarfinkel @mBohlega @Tapatio117 @DoctorVig @travishughes @activist_doc @franklybryan @_HarryPaul_ @Baker_C23 @FZghyer @RamlaKasoziMD @_blake_smith @LizzyHastie @AzeemRathore_ @AchantaAditya @Jcortesizaguirr @ShrutiKoti

@Azooz_Asbeutah @saipeeps @JordanSell22 @RizwanDania @Kaitlyn_Rogers9 @LawrenceWuMD @buckeye_sanjay @dmottacalderon @vikramagn @maheen_ihsan @efloyd14 @cobbnotgrey @Azooz_Asbeutah @onsarigo93 @Dayyan95 @tarheel_doctor @Anouf14 @VCU_IMRes @coyefish379 @amrmousa96 @Elizabe19893579

@md_anusha @RizwanDania @TheRealDSrini @Flower_freeland @pri_athavale @KromerHaylie @AaronLBerkowitz @G_Khafaji @MariaMjaleman