21/M w/ 2 days abrupt fever, sore throat. No cough/rhinorrhea, rigors, hoarseness. Exam: b/l tonsil exudates, +tender cervical LAD, no neck swelling. No PMH, allergies. Sexually active w/ female partners, no prior STI. 4th gen HIV(-), rapid Strep(-). W/c of the ff is correct?
1/16
Strictly based on guidelines, 31% got the correct answer -- observe/counsel. At some point in our practice, we might have done any of the above choices, which might seem reasonable.
The goal of the Tweetorial is to discuss evidence behind Abx prescription for pharyngitis.
2/16
Respiratory viruses cause the majority of acute pharyngitis (up to 45%). Group A Strep (GAS) is the major bacterial cause & the main indication for Abx. But, it comprises only 10% of acute pharyngitis (higher in other areas).
3/16
Why do we prescribe Abx for GAS? Meta-analysis bit.ly/2PmdXZP
▪️ ⬇️ SSX, transmission
▪️ ⬇️ complication rates: peritonsillar abscess (RR 0.15), otitis media (RR 0.3), acute rheumatic fever (RR 0.27); data for acute GN is inconclusive
4/16
However, the data presented 👆must to take into account:
▪️ Complications are rare. Data from a national database in the UK: # needed to prevent 1 peritonsillar abscess was >4,000! bit.ly/2I4hKHb
▪️ Widespread inappropriate Abx use bit.ly/2PnEzcR
5/16
Therefore, the question one needs to ask is which patient needs to be tested and treated for GAS.
𝓦𝓱𝓸 𝓽𝓸 𝓽𝓮𝓼𝓽?
▪️ Concurrent conjunctivitis, coryza, rhinorrhea, cough strongly suggest a viral etiology 👉 NO testing, Abx; only observe/supportive care
6/16
▪️ Centor criteria (1 point @ fever, no cough, tender cervical lymph node, tonsillar exudates)
👉 0-1: likely viral and not from GAS; NO testing, Abx; only observe/supportive care
👉 ≥2 or ≥3: perform rapid antigen test (RADT) +/- throat Cx bit.ly/2TbRW0D
7/16
RADT (Sn 86%) vs Cx (Sn of 90%). RADT advantage 👉 results available in minutes.
▪️ If RADT (-), Cx indicated only in:
1⃣ high risk of GAS complication (adolescents, immunosuppressed, prior h/o ARF)
2⃣ high GAS prevalence
3⃣ contact w/ high risk for GAS complication
8/16
𝓦𝓱𝓸 𝓽𝓸 𝓽𝓻𝓮𝓪𝓽?
▪️ ACP, CDC bit.ly/2wJE1rf, IDSA bit.ly/32sh8V8 recommend only in symptomatic patients w/ a +RADT/Cx
▪️ W/o +RADT/Cx, empiric Abx is discouraged as SSx of GAS & non-GAS pharyngitis overlap and can lead to inappropriate Abx use
9/16
10 day course of PCN or amoxicillin is recommended for GAS pharyngitis. Alternatives: cephalosporins, clindamycin, macrolides. Caution with macrolide use as rates of GAS resistance is increased in some areas.
10/16
In the approach to a patient with acute pharyngitis, it is 𝓲𝓶𝓹𝓸𝓻𝓽𝓪𝓷𝓽 to have illness scripts for other causes 👇
11/16
Acute HIV, fever/pharyngitis (much like mononucleosis), are very common 👇bit.ly/32yGOiZ
▪️ Warrants high index of suspicion. Opportunity for timely HIV dx. Remember that undiagnosed HIV contributes around 1/3 of HIV transmission 👇 bit.ly/2VhjtQW
12/16
In recent studies, Fusobacterium has emerged as a concerning cause of acute pharyngitis. As we know, it is the leading cause of the dreaded Lemierre Sx (covered here before bit.ly/2Vix8ax 👇) #spacedlearning#retrievalpractice
13/16
In this study by the legendary Dr. Centor @medrantsbit.ly/2Vjc2IZ as much as 21% of adults w/ pharyngitis had Fusobacterium (compared to 10% from GAS). This opened up a debate on whether one needs to routinely test and treat for Fusobacterium pharyngitis.
14/16
Fusobacterium, not routinely tested (unless you specifically ask Micro). Also, no rapid/readily available test & no study that empiric coverage prevents Lemierre.
Pls check out @PaulSaxMD beautiful discussion on this topic way back in 2015 👉 bit.ly/3c5PXnm!!
15/16
I also HIGHLY recommend listening to bit.ly/2Pn866h, an Annals On Call podcast on this debate featuring the leading experts on acute pharyngitis: Dr. Centor @medrants & Dr. Linder @jeffreylinder.
16/16
In summary:
▪️ Centor criteria can help select who to test (RADT/Cx)
▪️ Abx only for symptomatic patients w/ +RADT/Cx
▪️ Expand illness script for pharyngitis
ALWAYS observe for response & counsel for warning signs (neck swelling, chills, drooling, stridor, dyspnea, etc).
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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: