Time for some #SpacedRepetition from @CPSolvers @DxRxEdu @rabihmgeha
Some chat recap #ClinicalPearls and bonus pearls from #VirtualMorningReport on Friday Sept 25th clinicalproblemsolving.com/morning-report…
Case by the brilliant @Rafameed
A 31-year-old M born and raised in Brazil w/ no PMH presented with a 3 mon history of worsening DOE, orthopnea, 7kg weight loss, abdominal distention, dry cough, and syncope
Base rate of disease for an ID case with @k_vaishnani and @Rafameed is very high
An interesting fact from @3owllearning : Depending on the clinical problems, the studies of disease probability for differential diagnosis often show 10 - 25% of cases are unexplained, even after careful examination and testing.
Isn’t everything from Brazil Chagas?
In using Brazil as buzzword, endemic infections - Chagas, Leishmaniasis, yellow fever, paracoccidioides, leprosy, toxoplasmosis, sporotrichosis, Zika
His occupation is fisherman.. a clue or red herring?
Syncope could be from Pulm HTN. Patients with pulmonary artery hypertension (PAH) typically present with dyspnea, fatigue or chest pain. journal.chestnet.org/article/S0012-…
Most of the stuff we are familiar with has cutaneous manifestations
fresh water bugs- schistosomiasis, pseudomonas, aeromonas, NTM (marinum, ulcerans, avium), legionella, leptospirosis, naegleria
Here is a great case on SSTI from the water
But what about schistosomiasis causing portal HTN?
researchgate.net/publication/21…
Tricuspid regurg leading to liver failure⏭️to ascites causing abdominal distention
We have some interesting PE findings:
Auscultation showed a holosystolic murmur located at the left lower sternal border that augmented with inspiration. Auscultation also revealed a loud pulmonic component with a fixed split S2 combined with a right ventricle S4 gallop.
schistosomiasis is related to 1st group pulmonary hypertension
Here is a great one on PAH from @DxRxEdu
Outside of US, schistosomiasis the most common cause of Group 1 pHTN
is the fixed splitting of P2 from an ASD + Eisenmengers?
His abdominal exam shows hepatosplenomegaly and + hepatojugular reflux, 2+ LE edema
Accumulation of ascites in patients with RV failure can be due to high venous pressure reflecting back in the thoracic duct, slowing lymph drainage from the abdominal cavity through the cysterna chili.
Is there a BNP? would help to differentiate cardiac Ascitis with saag >1.1
Paracentesis shows a high SAAG of 1.4
SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid)
The Serum Ascites Albumin Gradient (SAAG) defines presence of portal hypertension (does not differentiate cause) in patients with ascites.
SAAG > 1.1 g/dL indicates portal hypertension is the cause of ascites with 97% accuracy.
mdcalc.com/serum-ascites-…
His CBC shows 15% eosinophils
A CT chest shows bilateral Pulm emboli, enlarged pulm vein
ECHO shows normal EF and mod TR with ⏫ Pulm press of 88
How do we tie all of this together?
THe emboli aren’t a perfect fit, but with eosinophilia, age, location, pHTN, really fits schistosomiasis well
Could the pulm filling defects be egg emboli....
Serology showed Schistosoma Mansoni
Here is nice review ncbi.nlm.nih.gov/pmc/articles/P…
He was treated with Prizaquental and sildenafil and he improved
How did this happen?
The eggs went to the portal vein causing periportal fibrosis ⏭️ shunting blood into pulm vessels ⏭️ eggs dislodge into pulm vascul ⏭️ granuloma formation causing pulm htn and all his symptoms
Case closed!
Check out this article by @DxRxEdu @rabihmgeha @Gurpreet2015 A Tough Egg to Crack
journalofhospitalmedicine.com/jhospmed/artic…
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