Thread by @WuidQ

Part 1/2 📌
32/M w/ 6 wks fever, abd pain, weight loss. Exam: tender RUQ, hepatomegaly. 🧪: WBC 3.1, Hgb 8, Plt 110; AST 62, ALT 70, Alk Phos 450, bili 0.8; RPR(-). HIV came back +, CD4 89. CT: scattered tiny heterogenous liver lesions. Path shown👇[Go to next tweet]

Part 2/2 📌 [case continued]
Path shown👆: multiple dilated blood-filled spaces surrounded by clumps of Warthin-Starry+ rods, AFB stain (-). Lives in Florida, no travel, previously healthy, worked as a cashier, no pets. What is the most likely opportunistic infection?

1/12
The majority got this one right - Bartonella. As @k_vaishnani @JosGilbertoMon1 @NateWarnerMD @Elennaro @ArmelleID correctly pointed, this is indeed a case of ⚡️bacillary peliosis (BP).

@MedTweetorials

Pictures taken from: bit.ly/3joTS2m

2/12
BP, like bacillary angiomatosis (BA), occurs only in the immunocompromised. Unlike BA, BP is only caused by Bartonella henselae. bit.ly/2CPkKaH

Review other Bartonella infections👇
[you don’t need cat exposure all the time]

@NNolanMD @LeMiguelChavez @Jncherabie

3/12
BP occurs in people with HIV & CD4 <100. Like MAC, p/w chronic fever and abd pain + characteristic lab feature of ⚡️alk phos ⬆️ out of proportion to AST/ALT. Other SSX: bit.ly/3joTS2m

▪️Heptomegaly/splenomegaly are common
▪️Co-occurrence of skin BA

4/12
Diagnosis:

▪️Put BP in the same bucket of “undifferentiated fever” as MAC (we’ve talked about this before #spacedlearning #WuidQchronicles) 👇

https://twitter.com/WuidQ/status/1225242606055165952

5/12
▪️Imaging: can show heterogenous-low attenuation lesions of various sizes in the liver +/- spleen 👇 (pic taken from bit.ly/3fE5axr)
▪️Gold standard in dx: biopsy. Bartonella serology can support dx.

6/12
Treatment: doxy x 3 months bit.ly/2WxH93k

Peliosis is not just caused by Bartonella as @k_vaishnani pointed. TB, syphilis, lymphoma, steroids, and chemo-/immunosuppressive drugs can also cause it.

Cause of peliosis from UpToDate👇

7/12
We’ve talked about Bartonella many times before. Time to review them #spacedlearning #WuidQchronicles

1️⃣ Bartonella bacilliformis (Orogya fever)👇

https://twitter.com/WuidQ/status/1048634997756682240

8/12
#WuidQchronicles

2️⃣ Bartonella in DDX of cat-associated infection (“My cat loves PPeanut BBuTTTer”) 👇

https://twitter.com/WuidQ/status/1148612804905177089

9/12
#WuidQchronicles

3️⃣ Bartonella (cat-scratch disease) as a cause of lymphocutaneous cellulitis 👇

https://twitter.com/WuidQ/status/1148607589200084993

10/12
#WuidQchronicles

4️⃣ Bartonella quintana as one of 3 infections from human body louse (a/w homelessness, poverty, war) 👇

https://twitter.com/WuidQ/status/1161066296022327296

11/12
#WuidQchronicles

5️⃣ Cross reaction b/n Q fever & Bartonella serologies 👇

https://twitter.com/WuidQ/status/1192867091008884736

12/12
#WuidQchronicles

6️⃣ And finally, we talked about Bartonella bacilliformis as important DDX for a positive “blood smear” in the boards 👇
(“My Boy Friend is BARack”)

https://twitter.com/WuidQ/status/1190028818070851584