32/F, 12 wks pregnant p/w malaise and rash. Exam: diffuse maculopapular rash including palms/soles. HIV (-), RPR 1:128. No prior h/o STIs or other PMH. No headache, blurred vision, normal neuro exam. No genital lesion. Most appropriate treatment? #IDMedEd#syphilis
(1/11) The correct answers are A (34%) & B (13%). Note case should’ve mentioned +confirmatory test. Cases of congenital syphils >doubled from 2013 (362 cases) to 2017 (918 cases), coincident w/ the rise in primary & secondary syphils rates among all women cdc.gov/std/stats17/sy…
(2/11) Untreated maternal syphilis, in up to ✔️80% of cases, leads to severe adverse pregnancy outcomes (congenital infection, stillbirth, premature birth, neonatal death). #IDMedEd#syphilis
(3/11) PCN is the 🌟ONLY effective Tx for preventing congenital transmission. PCN remains the DOC for syphilis. TP remarkably has not developed PCN resistance over time unlike other bugs. This @tony_breu tweetorial on why this is so is 🌟highly recommended
(4/11) Pregnant women with syphilis should be treated 📌ACCORDING to their stage of infection. Remember, neurosyphilis can occur during 🌟ANY stage. Thus, a good history and physical/neuro exam are essential in diagnosing and treating syphilis appropriately. #IDMedEd
(5/11) In our case, the diffuse MP rash involving palms/soles is a hallmark of 🌟secondary syphilis. Have you wondered why syphilis rash loves to involve the palms/soles (& why the lesion is painless)? I highly recommend this tweetorial #IDMedEd@tony_breu
(6/11) PCN x 1 (2.4 M units) is a correct answer here (standard Tx of primary, secondary & early latent stage syphilis). The CDC guideline also highlights the benefit of a 2nd dose of 2.4 M units 1 wk after the initial dose among ✔️pregnant women #IDMedEdcdc.gov/std/tg2015/syp…
(7/11) Note that the 2nd dose of PCN for early stage syphilis among pregnant women as acknowledged by the CDC guidline is based on expert opinion derived from PCN pharmacokinetic data during pregnancy and studies that showed benefit. #IDMedEdncbi.nlm.nih.gov/m/pubmed/12353…
(9/11) When syphilis is dx during the 2nd half of pregnancy, fetal US should be performed to evaluate for congenital syphilis. #IDMedEd#syphilis
(10/11) If Tx results to Jarisch-Herxheimer in women tx during the 2nd half of pregnancy, can be at risk of premature labor (increased awareness of symptoms & obstetric attention needed; stillbirth rare but concern for this should not delay necessary Tx) cdc.gov/std/tg2015/syp…
(11/11) Let’s hear more from our syphilis expert @hrenoID regarding screening and treatment of maternal syphilis & prevention of congenital transmission. #IDMedEd#syphilis
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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).
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.
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
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.
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.
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).
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: