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Nov 5, 2019 11 tweets 7 min read Read on X
#IDgrandrounds
40M, late summer, +sudden R facial weakness, diplopia, dysphagia; later,+UE weakness; lives in Colorado, loves to hike, had a lot of tick bites.

What are your differential Dx?
@BradCutrellMD @Cortes_Penfield @DocWoc71 @Darcy_ID_doc @TxID_Edu @GermHunterMD
@BradCutrellMD @Cortes_Penfield @DocWoc71 @Darcy_ID_doc @TxID_Edu @GermHunterMD 1/10
CASE CONTINUED.

Stroke team activated upon ED arrival.

2 household members were rushed to the hospital for paralysis & respiratory compromise. Unfortunately, both died. All reported consuming home-canned food.

ID was called. CDC alerted & antitoxin flown in. Image
2/10
CASE RESOLUTION: Foodborne botulism

@Cortes_Penfield @TxID_Edu @BradCutrellMD & @JIOReilly highlighted the important DDx for this case.

Many ID Dx can p/w various neuro ssx depending on the direct/indirect involvement of the central/peripheral nervous system
3/10
ID illness script for patient w/ extremity weakness +/- cranial nerve involvement should also consider, among many things:

✔️Paralysis progression

▪️ Ascending paralsysis (extremities 1st ▶️ CN's later)

👉 GBS
👉 WNV
👉 Tick paralysis
👉 Most causes of flaccid paralysis
4/10
▪️ Descending paralysis (early CN involvement ▶️ extremities, like in this case)

👉BOTULISM is the 🌟classic example (most common at onset: diplopia, dysphagia, blurred vision, facial weakness, ptosis)
👉Diphtheric polyneuropathy (exceedingly rare; can be ascending too)
5/10
✔️ +/- Fever

▪️ No fever: GBS, tick paralysis, botulism, some viral causes of flaccid paralysis

▪️ Usually with fever: WNV
6/10
✔️Sensory involvement:

▪️ + involvement: GBS (usually)
▪️ No involvement (to mildly +): WNV, tick paralysis, botulism

✔️Mental status

▪️ Intact: GBS, botulism, tick paralysis
▪️ +change: WNV (depending on +/- encephalitis)
7/10
Many other things to consider in the illness script especially if you want to entertain non-ID Dx:

✔️Deep tendon reflexes, NCV/EMG, CSF findings.

A good review here: academic.oup.com/epirev/article…
8/10
‼️ Botulism can rapidly progress from mild illness to fulminant disease that can end in death within 24 hours.

Case highlights the importance of EARLY recognition of botulism:
✔️Descending paralysis w/ early CN involvement
✔️No fever, intact mental status, no sensory change
9/10
Once suspected, check state requirements and notify early.

Botulism is Category I (A) state reportable disease. Must be immediately reported by phone, fax, rapid communication upon ✔️1st knowledge OR ✔️ suspected.

Also category A bioterrorism agent.
10/10
For further review, botulism was covered previously at WuidQ:

(1)

(2)

Many thanks again to our brilliant fellow @LauraMarks5 for presenting the case and highlighting important points about botulism! #Idmeded

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More from @WuidQ

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
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
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
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
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
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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