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WuidQ: Washington University ID Questions Profile picture
@WuidQ
Apr 12, 2019 • 9 tweets • 4 min read • Read on X
19M +fever/cough x 2wks. Exam: n/l except draining fluctuance on chest. CT: lung abscess adjacent to skin. Cx: Aspergillus nidulans. 6mos ago skin abscesses 2/2 Burkholderia. 1yr ago, pneumonia 2/2 Serratia. HIV(-). CBC nl. Test for most likely underlying immunodeficiency?
1/8) Answer: dihydrorhodamine test. Case of chronic granulomatous disease (CGD), one of the primary immunodeficiencies that can sometimes present in adulthood similar to common variable immunodeficiency (CVID), GATA 2 deficiency, hyper IgE syndrome (Job syndrome). #IDMedEd
2/8) GATA 2 deficiency was previously quizzed. Check it out again: . #IDMedEd #immunodeficiency Image
3/8) Main problem in CGD ✔️genetic mutation (X-linked or autosomal dominant) ➡️ deactivates NADPH ➡️ phagocytes fail to generate superoxide radicals/H2O2 ➡️ fails to generate proteases that kill 🌟 catalase (+) organisms. #IDMedEd #CGD
4/8) Why ⬆️ risk for catalase (+) organisms? Bacteria ✔️produce H2O2, catalase ✔️neutralizes H2O2. Bacterial H2O2 ➡️ used by the defective CGD phagocytes to its advantage & ✔️kills the bacteria. Thus, catalase (-) bacteria ➡️ +H2O2 ➡️ avoids infection in CGD patients. #IDMedEd
5/8) Recent studies show that above pathophysiology maybe an oversimplification. Catalase positivity not an essential component to establish infection. Exact pathophysiology remain to be elucidated. #IDMedEd
6/8) When to suspect? Recurrent bacterial/fungal infection (skin > lung) w/ mostly catalase +/unusual bugs. 📌💯Top 5: Aspergillus, Staph aureus, Burkholderia, Serratia, Nocardia. Others: BCG, Salmonella, NTM, TB. No risk✖️for viral infection. #IDMedEd
7/8) Dx: high index of suspicion, neutrophil function test. Test of choice: dihydrorhodamine (DHR) test + genetic testing. DHR now preferred over nitroblue tetrazolium (NBT) test. Both tests rely on color changes as a result of superoxide generation. #IDMedEd
8/8) Tx: early diagnosis, aggressive management of infection, antimicrobial prophylaxis (longterm sulfa/TMP, itraconazole), +/- interferon gamma. #IDMedEd

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More from @WuidQ

WuidQ: Washington University ID Questions Profile picture
Jan 6, 2021
38/M w/ progressive loss of scalp, axilla, and chest hairs. Recently dx w/ HIV 6 mos ago when he developed dissem cryptococcosis. He has now been taking TDF/FTC, raltegravir, TMP/SMX, azithromycin, & fluconazole x 6 mos. Drug-induced alopecia is suspected. Most likely culprit?
1/8 Nice job! 52% got the right answer, fluconazole.

In animals/humans, fluconazole has been shown to induce telogen effluvium bit.ly/2MMnF9j, one of the most common causes of nonscarring hair loss (see Table 👇 bit.ly/38rTXyN).

@LParraRod @NNolanMD Image
2/8
 Normal hair cycle: anagen (growth) 👉catagen (transformation) 👉telogen (resting) 👉 shedding. Cycle is asynchronous (no mass hair shedding). At any given time, 90% of hair are in anagen, 1% in catagen, 10% in telogen.

@ID_fellows @PBMazi @LeMiguelChavez @gayathri25788
Read 9 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 24, 2020
32/M, h/o HSV encep 1 mo ago (s/p 21 d ACV), on ceftri/metronidazole for sacral OM, p/t ER +delusion, fever, seizure. CSF: WBC 25 (L>N), ⬆️TP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
b/l temporal lobe enhancement ⬆️ from prior. Whch of the ff is the best Tx for this condition?
1/11
The group is split b/n steroids & d/c metronidazole. The answer here is Tx w/ steroids. Indeed, this is a case of autoimmune post-HSV encephalitis (anti-NMDA receptor encephalitis post-HSV). Good job @LemuelNonMD
@LeMiguelChavez @adilrashid83 @Orchid10Tree @KhalafSuha
2/11
Metronidazole-induced encephalopathy is predominated by cerebellar Sx w/ a distinct involvement of the dentato-rubro-olivary pathway on imaging. We’ve talked about it here before. Refer👇for further discussion
Read 12 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 19, 2020
67/M w/ poor control DM, BPH, +10 d dysuria. T38.1, BP 120/80, +tender R CVA. WBC 14. U/A: 21 WBC, UCx: (-)bacteria, +Candida glabrata (fluc-R) x 2 samples. BCx(-), CT: +prostate hypertrophy. Has had no response to ceftriaxone. Has no Foley cath. Which of the ff is indicated?
1/15
The vote is split b/n micafungin and ampho deoxycholate! Thank you for all your responses!

Although micafungin may be a reasonable option, the correct answer here is ampho deoxycholate.

In this tweetorial, we will talk about Candida UTI and its treatment.
@ID_fellows
2/15
Candiduria can be challenging as it can potentially indicate: colonization, UTI, or candidemia/disseminated infxn.

Candiduria from a clean-voided urine sample is uncommon (<1%); more commonly seen in hospitalized patients w/ an indwelling bladder cath.
Read 16 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 16, 2020
ID Miscellany|physical Exam|Signs|Humanities #idmesh
1/20
𝙁𝙀𝙑𝙀𝙍 𝙋𝘼𝙏𝙏𝙀𝙍𝙉𝙎: 𝘼 𝙇𝙊𝙎𝙏 𝘼𝙍𝙏?

Great! Three quarters find inquiring about fever patterns still useful. We will review some of the most important fever patterns.

@ID_fellows

2/20
For centuries, physicians have relied upon meticulous observations to dx infections. For many years, observation of the fever pattern provided physicians w/ important diagnostic clues. However, the advent of abx & advanced dx & imaging has changed this landscape. #idmesh
3/20
Swift initiation of abx & antipyretics make it impossible to verify historical descriptions of certain fever patterns. Hence, inquiry into fever patterns loses its clinical significance bit.ly/33iXCLs.
Read 21 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 11, 2020
29M w severe persistent asthma p/w recurrent exacerbations despite optimal LABA/intranasal steroids. Abs eos 1250, total Ig E 1500, CT +mucus plugging, central bronchiectasis upper-middle lobes. Originally from Mexico, now in Texas. Which of the ff tests is indicated?
1/10
Great job! The majority got the right answer, allergic bronchopulmonary aspergillosis (ABPA).

Recurrent asthma exacerbations despite optimal asthma therapy & eosinophilia a/w mucus plugging and multilobar central bronchiectasis should raise suspicion for ABPA.
2/10
Aspergillosis, classified as saprophytic (aspergilloma), allergic (ABPA, hypersensitivity pneumonitis, allergic sinusitis), or invasive (pulmonary, other organs).

ABPA: hypersensitivity to A. fumigatus; can also occur from other fungi (referred as ABPM, M for mycosis).
Read 11 tweets
WuidQ: Washington University ID Questions Profile picture
Jul 31, 2020
48M +cirrhosis, underwent routine large volume paracentesis. +Abd fullness, (-)fever, abd pain/tenderness, confusion. Ascitic fluid: light yellow, 100 PMNs, SAAG 1.5, Cx +pan-susc E. coli. WBC 8, Crea 0.8, bili 1.8. Which of the ff is best management for this patient?
1/5
 Only 21% got this right: no abx, repeat para in 48H.

The dx of spontaneous bacterial peritonitis (SBP) rests on finding >/= 250 PMNs/mm3 in the ascitic fluid. Most patients with SBP are symptomatic (only 13% with no symptoms bit.ly/3gp5nEU)
2/5
The patient in our case is asymptomatic (no fever, abdominal pain, mental status change 👉most common SBP symptoms) and the ascitic fluid is <250. This is a variant of SBP known as:

▪️Monomicrobial nonneutrocytic bacterascites (MNB)
Read 6 tweets

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