Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

June 17th Day 74: clinicalproblemsolving.com/morning-report…

w/ @abdallah_tom & @sargsyanz @StephVSherman @DxRxEdu @rabihmgeha

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

Let's start with a problem representation:

26 yo/ F presenting with 1 month of fevers, throat swelling, headaches, lower abdominal pain, dysuria, weight loss (9kg), lymphadenopathy, and a rash previously seen and tx for presumed STI 2 weeks ago without improvement

But first, a moment to reflect:

When treating an infection, especially a UTI, remember:

Were diagnostic tests to confirm/exclude UTI done at the time of the initial diagnosis?

If no response to abx and no culture was sent then think GC or STD like mycoplasma genitalia

maybe syphilis. body aches, rash, fevers

or TB depending on where in world this is (@AnnKumfer right out of the gates)

If she was given Macrobid for her UTI when she had pyelo it would not work as it has poor penetration to the kidneys.

What was the rash (papules or pustules suggesting gonorrhea)

What about UTI w/ a co-infection, or following the noninfectious route based on geography & epidemiology

“a dog can have both ticks & fleas”

Here is a short thread on mycoplasma genitalia as it seems to prevalent and doesn't resolve with standard STI tx,

https://twitter.com/RosenelliEM/status/1272108597447704577

What about sterile pyuria?

It is the persistent finding of white cells in the urine in the absence of bacteria

13.9% of women & 2.6% of men are affected

Gonorrhea is a cause of sterile pyuria

Leuk est has a sens of 66.7%/ gonorrhea & 60.0%/chlamydia

nejm.org/doi/full/10.10…

If this is sterile pyuria activate schema including infectious: viral CMV, EBV, bacteria: AFB, mycoplasma, ureaplasma, STI, parasites, other: reactive arthritis, AIN, chronic pyelo ect, surrounding inflammation in pelvis etc.

Wouldn't expect to see pyuria w/ syphilis though

Lots of different symptoms at play here.

I would think the rash and body aches could be a rxn to the ABs.

Fever and UTI could be another set of problems

Diptheria could explain the throat and fevers

Schema for pharyngitis,

https://twitter.com/AlexHorneMD/status/1263490062706020353?s=20

Her GI symptoms were also driving the possibility of Chron's disease or Ulcerative colitis leading to Fistula formation

Just using the Imade pneumonic, Infection, malignancy, and endocrine still at play. Drugs can be ruled out

She has right supraclavicular lymphadenopathy.

Does malignancy produce painful lymphadenopathy?

Yes, in rare cases, painful or tender lymphadenopathy can result from hemorrhage into the necrotic center or from pressure by rapid tumor expansion aafp.org/afp/2002/1201/…

Virchow’s node in L supraclavicular,

It is a well-known signal node for spread of gastric cancer as well as intestines, GU system, esophagus, common bile duct, liver, pancreas, and lung, ncbi.nlm.nih.gov/pmc/articles/P… & ncbi.nlm.nih.gov/pmc/articles/P…

R-sided SC node R lung, arm & face

In reevaluating iMADE & see if we can overlap.

Infectious: EBV, CMV, toxoplasmosis, HIV, syphillis, TB, fungal, parasites with schistosomiasis

Autoimmune: sarcoid or SLE, Castleman's, Bechet's, Stills,

Someone mentioned leishmaniasis. who.int/leishmaniasis/…

Bilateral supraclavicular nodes: metastasis of breast and bronchus malignancy

CRP is more acute inflammation compared to sed rate is more chronic inflammation, ncbi.nlm.nih.gov/pmc/articles/P…

IBD with sweet syndrome
ncbi.nlm.nih.gov/pmc/articles/P….

Abrupt onset of fever,⏫WBC, & a painful red, papular skin rash, w/ a neutrophilic infiltrate of dermis on histology

It is assoc w/malignancies (hematological), infections, IBD, pregnancy & drugs such as granulocyte colony-stimulating factor

She also has anemia. A schema awaits

CT scan showing lots of necrotizing lymphadenopathy!

Time for a biopsy....

Now we have lymphadenopathy with central necrotization!

TB can cause papulonecortic tripanids

What about Kikuchi's disease, one of @rabihmgeha favorite dx. But what is it?

Kikuchi disease is a rare histiocytic necrotizing lymphadenitis, was originally described in young women and is a rare, benign condition of unknown cause usually characterized by cervical lymphadenopathy & fever.

EBV/ other viruses can trigger Kikuchi ncbi.nlm.nih.gov/pmc/articles/P…

Final dx, Tuberculosis Lymphadenitis.

TB has a prevalence of approximately 8 million individuals each year, and 3 million individuals die of complications related w/ the ailment.

Extra pulmonary TB is rare occurring in 0.05-5% of patients with TB

ncbi.nlm.nih.gov/pmc/articles/P…

Just remember, He who knows syphilis (and TB), knows medicine. pubmed.ncbi.nlm.nih.gov/23958805/

A great recap pictorial !

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