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/…
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/
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…
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
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
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.
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
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.
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.
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.
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
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.