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Jun 12, 2020 โ€ข 13 tweets โ€ข 6 min read โ€ข Read on X
Part 1 of 2
19M +3 wks fever, confusion. Exam notable๐Ÿ‘‡. Brain MRI +frontal lobe masses. CSF: lymph pleo, low gluc. CSF/blood cx, viral PCRs, Histo/Crypto/Blasto/Cocci(-). IGRA/AFB smear/Cx (-). Brain bx: granuloma, +necrosis, AFB/GMS/Cx(-). No response to Abx. ๐Ÿ‘‰ Part 2 Image
Part 2 of 2
Previously healthy, no PMH exc for recent dx of โ€œskin TBโ€ when he p/w nasal skin lesion ๐Ÿ‘†that showed granuloma w/ (-)AFB/GMS on skin bx. Started on RIPE 2 mos prior to presentation. Lives in rural Minnesota, (-)travel. Given SSx, w/c of the ff is the most likely Dx?
1/11 50% got the right answer! Nice job. A case of Balamuthia mandrillaris.

Balamuthia, one of the free-living ameba pathogenic to humans (like Naegleria & Acanthamoeba). Like Acanthamoeba, causes granulomatous amebic encepahlitis (GAE).

Pic in MCQ from bit.ly/2YNQFjs
2/11 Balamuthia GAE causes brain abscesses, that maybe ring-enhancing & a/w edema/hemorrhage. Patients p/w headache, seizure, confusion, fever. CSF shows lymphocytic pleocytosis, high protein, and low-normal glucose ๐Ÿ‘‰ difficult to distinguish from fungal/TB CNS infection.
3/11 As @RicardoLaHozMD pointed, one very helpful clue to Balamuthia is the presence of a characteristic rash in the central face/nose the usually precedes the onset of GAE by 2 wks to 2 yrs and is almost always visible on exam.
4/11 Note that this characteristic rash is almost always present in cases reported outside of the US (e.g. Peru) bit.ly/2YEDt09. But this is uncommonly reported in the US (only 6% of cases) bit.ly/2CfP4ev .
5/11 Nevertheless, in a patient who p/w brain abscesses, skin exam could give you clues and can lead to early diagnosis (think Nocardia). Rash, usually painless, nodular-plaque in the central face but can also be in the extremities ๐Ÿ‘‡bit.ly/2Y5Quk9 (esp elbow/knees). Image
6/11 Balamuthia, reported worldwide. US, common in California, Arizona and Texas๐Ÿ‘‡bit.ly/2CfP4ev. The ecological niche of Balamuthia is not well defined, unlike Naegleria & Acanthamoeba (water). Patients usually report soil > water exposure โ€ผ๏ธ bit.ly/30Ojvmf Image
7/11 Diagnosis is challenging ๐Ÿ‘‰ usually requires brain biopsy. Unlike Naegleria, ameba is not usually seen in CSF. H&E and PAS staining of tissues to see trophozoites & cysts. Requires PCR testing of tissues in most cases (hard to distinguish from Acanthamoeba on microscopy).
8/11 Balamuthia is a fatal disease. Treatment is usually delayed (esp in cases w/ no skin lesion) and ineffective (combination of different antimicrobials including: pentamidine, sulfadiazine, flucytosine, miltefosine).
9/11 Refer to Table ๐Ÿ‘‡ that summarizes the key features of Balamuthia GAE as compared to Acanthamoeba & Naegleria. #highyield @grepmeded Image
10/11 In summary, include Balamuthia in your DDX for brain abscesses of unknown etiology, esp in those w/ concurrent/preceding nasal/central face skin lesion. Closest DDX: fungal and TB. May require brain biopsy, contact health department to help w/ testing.

One more thing...
11/11 I always think that midline face/nose lesions can sometimes help you generalte DDX. See Table ๐Ÿ‘‡ @grepmeded #highyield . A case of Klebsiella rhinoscleromatis was one of the first cases we featured here at @WuidQ 2 years ago ๐Ÿ‘‰ Image

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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 ๐Ÿ‘‡ bit.ly/38rTXyN).

@LParraRod @NNolanMD Image
2/8
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.

@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), โฌ†๏ธTP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
b/l temporal lobe enhancement โฌ†๏ธ 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. Weโ€™ve talked about it here before. Refer๐Ÿ‘‡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
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).
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 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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