Travis Smith, DO Profile picture
Jun 12, 2020 32 tweets 38 min read Read on X
Before we begin, some great articles were shared regarding our current our pursuit for #Equality

huffpost.com/entry/black-me…

Forbes “Dear White People: Here Are 10 Actions You Can Take ….” #1 – Get to Know More People of Color…#10 – Speak up publicly forbes.com/sites/danabrow…
Let's start with a problem representation:

A 74 yo M with a PMH of myelofibrosis not currently under therapy and recently treated for CAP presents from his pulm clinic w/ SOB, recurrent fevers, and GERD like sxms found to have a recurrent infiltrate on Xray.
The first question is this another "CAP"

Is the patient on a JAK inhibitor? is patient pancytopenic?

That really impacts the ddx

We all wish we knew about Myleofibrosis..

A thread about the confusing "myelo" nomenclature by @DavidSteensma,
Myelo- comes from ancient Greek,in which the same word μυελός (myelos) was used to describe three things: bone marrow, the spinal cord, and, to a lesser extent, the brain.

Why the same word for these unconnected organs/tissues, Dr. Hippocrates?
I would assume immunocompromised host until prove otherwise

is this primary or secondary myelofibrosis as PV could lead to MF.

with MF I imagine cytopenias and a big spleen (sometimes a big liver)
Anyone familiar with Wacker’s triad? A Triad for the Diagnosis of Pulmonary Embolism and Infarction from 1961.

Serial measurements of the serum LDH, SGOT (serum glutamic oxalacetic transaminase) activity, & serum bilirubin concentration. jamanetwork.com/journals/jama/…
Has anyone seen Dr. Redelmeier’s essay about why we should no longer teach triads? onlinelibrary.wiley.com/doi/abs/10.111…

Back to this "infiltrate" is the infiltrate in the lung infectious/inflammatory noninfectious or something else (cells?)

A good 2 view (PA & LAT) can really help
Cool genetics of MPN: JAK2 > CALR & MPL, although plenty of other genes can be mutated, and a subset are “triple-negative”

ALR is an ER chaperone protein, & MPL is the TPO receptor,which makes total sense for a MPN!

typical tx for primary MF=ruxolitinib, ncbi.nlm.nih.gov/pmc/articles/P…
it's never a "CAP" until treated as CAP

pulmonary extramedullary hematopoiesis (EMH) can do this — thorax.bmj.com/content/68/2/1…

Rigors are actually a good predictor of bacterial infection
@haematognomist MPN pearls, in this case for Polycythemia Vera. The CYTO-PV trial showed that “among patients with JAK2-positive polycythemia vera (PV), maintaining a target hct of <45% has a🔽rate of fatal & non-fatal cardiovascular or thrombotic events vs hct of 45-50%.”
Since pt was on ruxolitinib it created some chat

The most frequent infections on jak inhibitors per case reports, were tb (N = 10), hep B reactivation (N = 5) & PJP infection (N = 2). pubmed.ncbi.nlm.nih.gov/29150886/

baricitinib is a new jak inh tested in COVID, contagionlive.com/news/arguing-t…
JAK2 inhibitors do not affect stem ... the spleen shrinks bc MF progenitor cells undergo apoptosis ashpublications.org/blood/article/…

Recent trial for ruxolitinib being used for GVHD
nejm.org/doi/10.1056/NE…

The pt is a plumber and works under houses, we are all having 🐀 nightmares
His work history opens theories of fungal infections in NC. Histo? Blasto?

CD doesn’t list any reportable fungal diseases for NC, cdc.gov/fungal/fungal-…
Histo map,images.app.goo.gl/duZ5v11cFhZ2vt…

usually aspergillosis requires pretty bad neutrophils not working, aspergillus.org.uk/content/neutro…
Cool peripheral smear that can be seen in the setting of fibrosis is the “teardrop” cells

Plumbers associated with asbestos glioblastoma bc of the glue they use, ncbi.nlm.nih.gov/pmc/articles/P…

Throwing someone on a fluoroquinolone first line for cap just grinds some of our gears Image
"antibiotic refractory pulmonary syndrome" a new fun term

Could this be TB? linezolid, quinolones and macrolides treat TB and could have been given for CAP.

Ruxolitinib discontinuation can cause ARDS — researchgate.net/publication/26…
For someone with an established condition, now w/ new illness:

1. Is it a flare of that disease (ds)?
2. Is it a complication of that ds?
3. Is it a complication of the tx for that ds?
4. Is it something entirely new?

And infiltrates could be non-expectorated alveolar blood
Intermittent hemoptysis without progressive lung disease also makes me think of HF & lung AVMs

Inhibition of JAK-STAT signaling pathway by Ruxolitinib results in a dramatic🔽in levels of inflammatory cytokines, such as IL-6 & TNF-α.
maybe increased risk of TB w/ tnf being low?
Faget’s sign -have learned to reflexively look at at med list

Big spleen, lung infiltrate, fingernail bruise. hmm..

is it a splinter hemorrhage?

disseminated fungi like Fusarium, blasto, candida can be at play here

i still think we need a ct and bal/biopsy
Hantavirus would usually have elevated hematocrit + bandemia + atypical lymphs,, cdc.gov/hantavirus/tec…

Invasive Fungal Disease After Remote Inoculation in Transplant Recipients,
pubmed.ncbi.nlm.nih.gov/21148507/
Most common rhythm in pe is ST, 10%–25% of patients with PE have a normal ECG.

A true left shift is when there are bands

Biatriospora mackinnonii infection, a form of phaeohyphomycosis. Think brown-pigmented (dematiaceous) molds, which can often get inoculated thru trauma
We cannot memorize everything but know that it occurs will prompt us to look it up

His chronic ppi leading to him to be predisposed to something? This study found the risk of pneumonia increased by 55% in patients who were taking PPIs ncbi.nlm.nih.gov/pmc/articles/P….
ICU patients using pump inhibitors have a three-fold increased risk of developing VAP vs H2-blocker receivers, ncbi.nlm.nih.gov/pmc/articles/P…

He drinks alcohol daily & has posterior infiltrate: Could be aspiration

Is this Drug induced penumonitits, pneumotox.com/drug/view/653/…
Pigeon droppings appear to be the most important source of the disease fungus Cryptococcus neoformans in the environment,

HEALTH HAZARDS ASSOCIATED WITH BIRD AND BAT DROPPINGS, idph.state.il.us/public/hb/hbb&…
Recurrent pneumonia different from non-resolving pneumonia….recurrent pneumonias resolve then come back….most common cause of recurrent pneumonia is aspiration

Final dx: Recurrent aspiration w/ pneumonitis related bleeding

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More from @RosenelliEM

May 30, 2021
Some cool #Syphilis Pearls from an article that @k_vaishnani shared ncbi.nlm.nih.gov/pmc/articles/P… Primary syphilis first manifests into a painless chancre at the site of inoculation 1 to 6 weeks later…
Hematogenous dissemination then can occur typically 4 to 10 weeks later, giving rise to secondary syphilis. <40% of pts w/ syphilis have primary syphilis diagnosed. These “Secondary” lesions last for several weeks before spontaneously resolving. Coined “early, latent infection”
What does late infection mean? When syphilitic lesions recur after 1 year from the initial eruption, or seropositivity is detected more than 1 year after the initial eruption, it is termed late latent syphilis.
Read 5 tweets
May 29, 2021
Some optics neuritis pearls in a short #Medtweetorial 🧵…. We all know that optic neuritis is frequently associated with multiple sclerosis (MS). But optic nerve inflammation can exist from autoimmunity, infection, granulomatous disease, paraneoplastic disorders, & demyelination Image
Classical ON from MS is unilateral, moderate, painful color vision loss with an afferent pupillary defect & normal fundus examination.
In those with ON, 95% of patients showed unilateral vision loss & 92% had associated retroorbital pain that frequently worsened w/ eye movement.
Read 14 tweets
Oct 1, 2020
If you have not listened to the @CuriousClinPod most recent podcast (Episode 10: Why does metronidazole treat both bacterial and parasitic infections?) then I suggest you tune in.

curiousclinicians.com/2020/09/30/why…

I'll summarize their show notes here in short #medtweetorial
First a question:

Was metronidazole first used as an antibiotic or as an antiparasitic?
If you guessed antiparasitic, then you would be correct!

It was developed in the 1950s to treat the parasite trichomonas & then was used in the 1960s to treat other parasitic infections, like giardia and amoebiasis.
Read 14 tweets
Oct 1, 2020
When you order a serum alcohol level, what does the lab measure? An answer and a quick #Medtweetorial on false elevations in #ETOH
If you guessed NADH, you would be correct.
Most lab assays for serum alcohol utilize a reagent containing alcohol dehydrogenase & NAD+

This is used to convert all present ethanol to acetaldehyde

Thereby reducing present NAD+ to NADH.
Read 11 tweets
Sep 26, 2020
A Teal pain in the neck:

Follow along for a short #medtweetorial on #CervicalArteryDissection

or see the full handout here emboardbombs.com/s/Cervical-Art…

from @EMBoardBombs @blakebriggsMD @IltifatMD
This review will focus on spontaneous dissections, not traumatic, as well as the pathophys, risk factors, presentation, diagnosis, and management.

Cervical artery dissections are a common cause of stroke in young(<50 years )w/ some reports of up to 20% being from dissections
Much like aortic dissections, there is some loss of structure along the wall of either the internal carotid artery or vertebral artery

This allows blood to collect within the intima.

In patients <50 years old, cervical artery dissections account for 20% of ischemic strokes.
Read 24 tweets
Sep 26, 2020
Time for some #SpacedRepetition from @CPSolvers @DxRxEdu @rabihmgeha

Some chat recap #ClinicalPearls and bonus pearls from #VirtualMorningReport on Friday Sept 25th clinicalproblemsolving.com/morning-report…

Case by the brilliant @Rafameed Image
A 31-year-old M born and raised in Brazil w/ no PMH presented with a 3 mon history of worsening DOE, orthopnea, 7kg weight loss, abdominal distention, dry cough, and syncope

Base rate of disease for an ID case with @k_vaishnani and @Rafameed is very high
An interesting fact from @3owllearning : Depending on the clinical problems, the studies of disease probability for differential diagnosis often show 10 - 25% of cases are unexplained, even after careful examination and testing.
Read 17 tweets

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