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Dec 18, 2019 โ€ข 15 tweets โ€ข 10 min read โ€ข Read on X
ID Miscellany|physical Exam|Signs|Humanities #idmesh

๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง

1/11
Is an important clue for leptospirosis that may often be overlooked on exam.

Pic from: link.springer.com/chapter/10.100โ€ฆ Image
2/11
What is it?

Simply put, it is a form of non-exudative conjunctivitis

1โƒฃ Non-exudative:

โ–ช๏ธ No purulent discharge
โ–ช๏ธ No matting of eyes in the morning
3/11
2โƒฃ Conjunctivitis: means that,

โ–ช๏ธ Pattern of eye redness ๐Ÿ‘‰ red, dilated vessels maximal at the periphery (from the palpebral to the bulbar conjunctivae) Image
4/11
It is NOT ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง if w/:

โ–ช๏ธ Ciliary flush (redness maximal in the limbus๐Ÿ‘‡) (1)
โ–ช๏ธ Eye pain (2)
โ–ช๏ธ Reduced visual acuity (3)
โ–ช๏ธ Pupillary abnormalities (4) ImageImage
5/11
Presence of above, ๐˜ช๐˜ฏ๐˜ด๐˜ต๐˜ฆ๐˜ข๐˜ฅ, would suggest (#'s refer to designation from above list):

โ–ช๏ธ Iritis (1, 2, 3, 4-constricted pupil/poor response)
โ–ช๏ธ Keratitis (1, 2, 3, hazy cornea)
โ–ช๏ธ Scleritis (2 โ€“ deep pain, ocular tenderness)

Lots of ID & non-ID DDX for above.
6/11
๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง is โ€œone of the most reliable and distinguishing features of leptospirosisโ€ (UpToDate).

When you do an online search for "๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง", 99% of the time, you will get โ€œleptospirosisโ€.
7/11
But when you look for DDX of non-exudative conjunctivitis (especially bilateral), youโ€™ll see that it can also be seen in a variety of conditions.
8/11
Differential diagnoses of B/L non-exudative conjunctivitis:

โ–ช๏ธ Viral, esp adenovirus & measles

โ–ช๏ธ RMSF (rarely) cdc.gov/mmwr/volumes/6โ€ฆ

โ–ช๏ธ Kawasaki๐Ÿ‘‡ link.springer.com/article/10.100โ€ฆ

โ–ช๏ธ Toxic shock syndrome๐Ÿ‘‡ jamanetwork.com/journals/jama/โ€ฆ ImageImage
9/11
But (+) ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง in a patient w/ ๐˜ฏ๐˜ฐ๐˜ฏ๐˜ด๐˜ฑ๐˜ฆ๐˜ค๐˜ช๐˜ง๐˜ช๐˜ค fever, in the right epidemiologic setting, should raise suspicion for leptospirosis.

๐Ÿ‘‰ Especially during the septicemic phase where SSX can be ๐˜ฏ๐˜ฐ๐˜ฏ๐˜ด๐˜ฑ๐˜ฆ๐˜ค๐˜ช๐˜ง๐˜ช๐˜ค Image
10/11
"Red eye" in ID is a helpful clue to a variety of conditions (ID & non-ID). At the ๐˜ฎ๐˜ช๐˜ฏ๐˜ช๐˜ฎ๐˜ถ๐˜ฎ, should examine:

โ–ช๏ธ Pattern of redness, vision, cornea, pain, pupils (direct/indirect, convergence)

As detailed above, can enrich clinical reasoning & form illness scripts!
11/11
In your practice, how often have you seen ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง? @DocWoc71 @CarlosdelRio7 @FungalDoc
@TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana
@DocWoc71 @CarlosdelRio7 @FungalDoc @TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana 11/11 extra 1โƒฃ
Thank you for all your responses. About 40% has not seen conjunctival suffusion.

How common is it? As high as 99%!! See Table ๐Ÿ‘‡ from cmr.asm.org/content/14/2/2โ€ฆ

What other SSX are common? Myalgia, as high as 100%! Headache, as high as 90%. Image
11/11 extra 2โƒฃ
In 1982, WHO introduced a criteria for leptospirosis dx in resource-limited settings (known as the ๐™๐™–๐™ž๐™ฃ๐™š'๐™จ ๐™˜๐™ง๐™ž๐™ฉ๐™š๐™ง๐™ž๐™–).
This has since been modified in 2013 (Sn 95%). ๐Ÿ‘‡ apps.who.int/iris/bitstreamโ€ฆ
ncbi.nlm.nih.gov/pmc/articles/Pโ€ฆ Image
11/11 extra 3โƒฃ
When I was training in the Philippines, where frequent outbreaks of leptospirosis occurs especially after a flood, we used the Faine's criteria.

It demonstrates the value of conjunctival suffusion & myalgia (esp of the calves) in suspecting leptospirosis.
11/11 extra 4โƒฃ
Look what Osler has to say about leptospirosis, in his first edition of Principles and Practice of Medicine (1st edition, 1892)!

At that time, it was a diagnosis of uncertain etiology, as originally described by Weil in 1886. @AdamRodmanMD @BedsideRounds ImageImage

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Jan 6, 2021
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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 ๐Ÿ‘‡ bit.ly/38rTXyN).

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Normal hair cycle: anagen (growth) ๐Ÿ‘‰catagen (transformation) ๐Ÿ‘‰telogen (resting) ๐Ÿ‘‰ shedding. Cycle is asynchronous (no mass hair shedding). At any given time, 90% of hair are in anagen, 1% in catagen, 10% in telogen.

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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), โฌ†๏ธTP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
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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. Weโ€™ve talked about it here before. Refer๐Ÿ‘‡for further discussion
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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
๐™๐™€๐™‘๐™€๐™ ๐™‹๐˜ผ๐™๐™๐™€๐™๐™‰๐™Ž: ๐˜ผ ๐™‡๐™Š๐™Ž๐™ ๐˜ผ๐™๐™?

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).
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Jul 31, 2020
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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 ๐Ÿ‘‰most common SBP symptoms) and the ascitic fluid is <250. This is a variant of SBP known as:

โ–ช๏ธMonomicrobial nonneutrocytic bacterascites (MNB)
Read 6 tweets

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