Thread by @ID_fellows

1/
Thanks to all that participated in our 1st live #IDFellowCase yest! Here is a wrap-up review tweetorial for reference + those who missed it.

Special thanks to @MDdreamchaser!

If you have feedback OR want to sign up to do a future case, use this form:forms.gle/cV4bRezYUCp6VR…

2/
A case of 70F with ring-enhancing brain/lung lesions was presented. Here is how @MDdreamchaser walked thru the case:
1⃣Define pt risk of infection (e.g. splenectomy, steroid use)
2⃣Take presenting clinical syndrome
3⃣Tempo of illness: abrupt? gradual?

3/
In this case, co-occurrence of brain-lung nodules was helpful clue

🖼️Infographic below

Also check out this 🧵 from @WuidQ

https://twitter.com/WuidQ/status/1245482594902388742

⭐️One other pearl. Embolizing disease might include endocarditis, Lemierre's dz, infectious aortitis, infected cardiac thrombus

4/
As the case continues, pt found to have endophthalmitis in light of persistent brain-lung lesions -- led to high suspicion for endocarditis --> at this point cx negative

BDG was very high in this scenario (>500). More on BDG next

5/ BDG
🔹Very high levels make FP less likely, can be clin useful in dx IFI
🔹⬆️BDG in many fungi except Mucorales,Crypto, Blasto
🔹🗝️: interpret in light of pt+clinical synd.This case = exceedingly rare for PCP, so think aspergillus, other molds, candida
@swinndong @AxellHouse⬇️

6/
Some pearls on AF resistant spp
⭐️Ampho-R fungi
C.lusitaniae (higher MICs to ampho)
C.auris (some)
A.terreus
Fusarium (some)
Scedosporium (Lomentospora) prolificans
Scedosporidum apiospermum (some)
Pseudallescheria boydii
Sporothrix schenckii

🔹Another from @k_vaishnani ⬇️

7/
We saw septated branching hyphae in this great📷: Aspergillus and Fusarium are prototypical. Can also include dematiaceous molds (Fontana Masson stain can differentiate this). Shape of conidia is helpful as well! Check out this infographic, adapted from ncbi.nlm.nih.gov/pmc/articles/P…

8/
Few notes on fungal endocarditis:
⭐️Most common cause = C.albicans > non-albicans Candida > Aspergillus > other
🔸Risk factors in recent yrs shift toward indwelling lines, immunocompromised hosts, IV drug use
🔸⬆️mortality

9/
Some of IDSA tx GL are in chart below: academic.oup.com/cid/article/63…

This pt transitioned to vori, plan for indefinite therapy due to endocarditis, MVR - but this can be difficult due to side effects

A reference for tissue penetration of AF fr @mmPharmD pubmed.ncbi.nlm.nih.gov/24396137/

10/
Some notes on vori:
🔹Non-linear kinetics
🔹QTC changes (⬆️vori/posa;⬇️ isav). @ConanMacDougall provided paper with some context for QTc prolongation academic.oup.com/jac/article/74…

🔹CYP interactions! is azole strong/mod/weak inhibitor?
▪️Tip fr @mmPharmD

https://twitter.com/mmPharmD/status/1300613904230502400

11/
We finished up with discussion on combination therapy for aspergillosis
⭐️Evidence is limited⭐️
🔸Theoretical issues with antagonisms with amphoB+azoles
🔸Excellent article that @TxID_Edu @MDdreamchaser like: link.springer.com/article/10.100…

12/
Few other pearls from: @A_Spallonii
🔸Thinking about breakthrough old infections, esp in H/O pts pubmed.ncbi.nlm.nih.gov/29860307/
🔸And this pearl:

https://twitter.com/A_Spallonii/status/1300604414038814720

13/
Hope you enjoyed the case. Here are some of the other links again:
Ellis: pubmed.ncbi.nlm.nih.gov/11118386/
Patterson: academic.oup.com/cid/article/63…
Marr: academic.oup.com/cid/article/39…
Martin-Pena: pubmed.ncbi.nlm.nih.gov/25048847/

14/
Can't wait to see you next time!!