Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

June 15th Day 73: clinicalproblemsolving.com/morning-report…

w/ @3owllearning @coyefish379 @onsarigo93 @DxRxEdu @rabihmgeha

Teaching points: clinicalproblemsolving.com/wp-content/upl…

Let's start with a problem representation:

A previously healthy 19-yo F presents with AMS following 3-days of a "cold-like illness" that started 5 days ago and was found to be hypotensive, febrile, tachynpneic, and dark crusting found in her pharyngeal mucosa

And right away we go to our MIST-pneumonic for AMS.

Priority should go to Toxins (drugs) and infection/inflammation in a younger patient with acute AMS

Or how about this one: VITAMINSS

Vascular, Infectious, Trauma, Metabolic, Neoplasia, Siezure, Structural

Things to think about include a meningoencephalitis

HSV encephalitis. possibly triggered by “URI”

We always think of HSV encephalitis as a no-miss diagnosis, it's prevalence is super rare. in France, for instance, no more than 50-70 "confirmed" cases /yr academic.oup.com/cid/article/49…

URI/sinusitis ---> brain abscess ---> seizure?

URI/sinusitis —> cavernous sinus thrombosis or bacterial meningitis

autoimmune/NMDA encephalitis is highly underdiagnosed, med.upenn.edu/autoimmuneneur…

the ⏫temperature def alters our problem representation. She definitely needs head imaging stat lp and abx.

Does she have any meningeal signs ? brain stem reflexes ?

Her⏫resp rate is likely compensation for metabolic acidosis

prominence of eyes - could this be thyroid storm?

Is this new diabetes?
diabetes could be contributing to dehydration and shock

mucor would make sense explains the aggressive progression overnight

mucosa crusting —> chronic rhonisinusitis

mucor would be unusual if she was immunocompetent

25% of T1DM p/w DKA as the initial presentation. Right on (at least in Kuwait in was),

"At the time of diagnosis, mild/moderate DKA was present in 24.8% of the children, while severe DKA was present in 8.8%."
ncbi.nlm.nih.gov/pmc/articles/P…

other things we want to know, which area is he from? any immunodeficiency? any exposures/travel history?

could be toxicities too, anticholinergic?

antimuscarinic syndromes - dry as a bone? As a Pharmacy student, she might have access to something?

But her pupils normal so anticholinergic less likely? Not if there are multiple drugs on board. This can throw off your exam. Lots of overdoses are polypharmacy.

ecstasy/MDMA can cause severe hyperthermia due to serotonergic effects.. also causes hyponatremia

I wonder if the prominent eye finding is related to retroorbital inflammation from an invasive infection

Some differentials for exophthalmos:

congenital, carotid-cavernous fistula (pulsatile exophthalmos), edema of structures behind eyes (Graves' disease, tumors, etc)

GPA also presents with exophthalmos, link.springer.com/article/10.100…

"Common signs & symptoms of orbital GPA include proptosis, epiphora, diplopia, sudden onset of pain, erythema, eyelid edema, & reduced vision. Proptosis is considered an important clinical sign in pts w/suspected GPA"

This patient looks like she is immunocompromised

the pivot point is the aggressive/super rapid decline in mental status

she is septic, she needs 30cc/kg bolus of LR (LR is the only real balanced solution). Dump the NS people, your kidney's hate it, especially your macula densa

We need to start pt on vanc ceftriaxone acyclovir and I don't think it's crazy to add iv ampho B

if no response to fluids,⏫eosinophils (points to lack of endogenous steroids) add steroids for septic shock

Was thinking about ADEM bc of encephalopathy following a recent illness

Hyperreflexia differentiates between serotonin syndrome vs NMS. NMS has more rigidity with really elevated CK levels, medsafe.govt.nz/profs/PUArticl….

On PE, the difference between anti cholinergic and sympathimimetic toxicity...

"prominence of both eyes" is this a potential sign of cerebral venous sinus thrombosis?

Classic inflammation w/ reactive thrombocytosis.

The MCC of a thrombocytosis is an essential thrombocytosis with infection being #1 most commonly from staph. ncbi.nlm.nih.gov/pmc/articles/P….

AGMA...with elevated glucose...DKA

but that normal sodium with that 480 glucose? corrected its 145 or so, simple math just add 2 to every 100 above 100. mdcalc.com/sodium-correct…

dx of dka requires glucose >250, bicarbonate <18, ph < 7.3, +ketones

Could this be Hyperosmolar Hyperglycemic State?

Unlikely given her 🔽bicarb, presence of ketones, &🔽 pH.

When we give insulin, the patient uses ATP, can precipitate severe hypophosphatemia

The hallmark feature of refeeding syndrome is hypophosphatemia ncbi.nlm.nih.gov/pmc/articles/P…

Inflammation anyone? thanks, @ytk_lau

https://twitter.com/ytk_lau/status/1272544396727255040

Proptosis / exophthalmos, examination from the side of the patient: nhs.uk/conditions/bul…

Looks like the final Dx is Rhinocerebral mucormycosis

Predisposing factors for mucormycosis such as hematological malignancies, severe burns, neutropenia, diabetes mellitus, and the use of corticosteroids.

Diabetic patients are predisposed to mucormycosis because...

....of the decreased ability of their neutrophils to phagocytize & adhere to endothelial walls. ⏫BG may also alter the ability of macrophages

ncbi.nlm.nih.gov/pmc/articles/P…

Proptosis is due to venous congestion in CSVT

Thanks for this GEM @LizzyHastie

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