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WuidQ: Washington University ID Questions Profile picture
@WuidQ
Nov 9, 2019 • 11 tweets • 8 min read • Read on X
#IDgrandrounds
30M +fever, ab pain, cough x 1wk. Back from Tanzania (swam in Lake Victoria) 2 mos ago. +vaccination/malaria prophy before trip. Blood smears (-). Eosinophil count 4,000.

Diagnosis/differentials? @Cortes_Penfield @TxID_Edu @BradCutrellMD @DocWoc71 @Darcy_ID_doc ImageImage
@Cortes_Penfield @TxID_Edu @BradCutrellMD @DocWoc71 @Darcy_ID_doc 1/10
Thank you for all your responses! @TxID_Edu @BradCutrellMD @DocWoc71 @GermHunterMD @marschall_jonas @jdcooperid others

Stool sample demonstrated Schistosoma mansoni eggs.

CASE RESOLUTION: Acute schistosomiasis (Katayama fever)

mcdinternational.org/trainings/mala… Image
2/10
Katayama fever was previously covered here last year. Click below to review:



What I'd like to talk about briefly is my "𝔸𝔹ℂ𝔻𝔼" approach to generating an illness script for a febrile returned traveler.
3/10
𝔸: "Adventure"

▪️ Where did patient travel?

Common DDX: "🅼🅳🆁🆃" Malaria, Dengue, Rickettsial, Typhoid fever

▪️ Malaria in all regions
▪️ Dengue less in Africa
▪️ Rickettsial illness more in Africa
▪️ Typhoid more in Asia

Good review here:
nejm.org/doi/full/10.10…
4/10
𝔹: "Body"

▪️ What syndrome does patient have?

Common syndromes (fever +) & examples:

▪️ Respiratory: flu, TB, fungal
▪️ GI: bacterial, helminthic, typhoid
▪️ Fever w/o localizing: malaria, dengue, rickettsial, typhoid

Always R/O malaria even w/ or w/o localizing signs.
5/10
ℂ: "Chronology"

▪️ When do the SSX start in relation to date of return?

Some infections have short incubation periods, hence, expected to manifest soon after return. See Table below: Image
6/10
𝔻: "Defense"

▪️ What pre-travel vaccinations/prophylaxis did patient receive?

Gives the clinician an understanding of patient's over-all risk for certain preventable travel-associated infections. Image
7/10
𝔼: 1st E "Exposure"

▪️ The crux of the ID history!

✔️ "Street" food consumption?
✔️ Unpasteurized milk?
✔️ African game reserve?
✔️ Flood, triathlon?
✔️ Hajj pilgrim? etc

Beware of "buzzwords" though as it may anchor you to a diagnosis and bias the rest of your approach
8/10
𝔼: 2nd E "Eosinophilia"

▪️ Helps generate DDX!

𝙷𝚎𝚕𝚖𝚒𝚗𝚝𝚑𝚒𝚌 𝚒𝚗𝚏𝚎𝚌𝚝𝚒𝚘𝚗: most important DX to consider
Protozoas not a/w eosinophilia except Dientameoba & Cystoisospora.

Will refer you to @DocWoc71 response for more info:
9/10
Using this approach, Katayama fever has this illness script:

𝔸 Vast majority come from Africa
𝔹 Rash ➕ respiratory/GI usually (pic)
ℂ Occurs late; 3-8 wks
𝔼 53.7% of eosinophilia from returned travel; exposure to infected water

Taken from: ncbi.nlm.nih.gov/pubmed/18458300 Image
10/10
Other things to know about Katayama:

1⃣ Happens in non-immune (travelers), rare in locals

2⃣ Rx is 𝗽𝗿𝗮𝘇𝗶𝗾𝘂𝗮𝗻𝘁𝗲𝗹 but is NOT larvicidal! Reason why a 2nd dose recommended 4-6 wks later.

3⃣ Steroids may be given w/ praziquantel (⬇️ inflammatroy response w/ Tx)

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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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