1/ Follow up for our #IDFellows and #IDTwitter on an #IDCase - 25 year old female with behcet's disease and chronic pain who presents for positive T Spot done for screening. Started on Rifampin for latent TB Infection. She calls 3 days later with diffuse pain.
2/ Great job, #IDTwitter, honing in on the issue! This was intentionally vague to stimulate discussion. As you alluded to, the key lies in what else she was taking. But first, what might we worry about as adverse effects Rifampin?
3/ Allergic reactions to rifampin are relatively rare though they have been described. However, patients may experience flushing, rash and itching that is unrelated to hypersensitivity. Rifampin can often be continued in these patients. PMID: 10575418
4/ A flu-like syndrome associated with Rifampin use has been described, which is manifested as fever, chills, myalgias and headache. The risk of developing this syndrome increases with increasing dose and is associated with intermittent rather than daily dosing.
5/ Interestingly this flu-like reaction is seemingly associated with antibody production. The above study, from 1971, documented the development of Rifampicin related antibodies in 1/3 of patients; mostly those who received intermittent dosing.
6/ Very rarely, Rifampin can cause liver dysfunction. This occurs more often when patients have underlying liver disease or in those receiving hepatotoxic agents. Other rare side effects include renal failure, hemolytic anemia, thrombocytopenia and possible DIC, and leukopenia.
7/ But Rifampin is most known for is its drug-drug interactions! It up-regulates the Cytochrome P450 CYP3A and P-gp multidrug efflux transporters which can impact the metabolism of many drugs. Though it is a bit dated, I still like this reference (doi:10.1001/archinte.162.9.985)
8/ In this #IDCase, the patient had been taking opioids for autoimmune associated joint pain. The addition of Rifampin resulted in increased metabolism of her prescribed opioid analgesics and re-emergence of her pain.
9/ Though it is common to think drug-drug interaction with Rifampin, it is important to assess for other adverse effects. When prescribing a new medication it is important to counsel on possible adverse effects and review med lists for possible #DDIs!
10/ Thanks for tuning in #IDTwitter! What Rifampin related stories do you have? Have you had Rifampin patients develop myalgias and flu-like illness? What surprising drug-drug interactions have you see?

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More from @ID_fellows

1 Sep
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


⭐️One other pearl. Embolizing disease might include endocarditis, Lemierre's dz, infectious aortitis, infected cardiac thrombus
Read 14 tweets
19 Aug
1/
72F with CML had persistent fever ~102F, cough. CT chest with focal consolidation in LLL. Sputum cx: Klebsiella pneumoniae. Serum BDG, GM negative.

Was on Vanc/Cefepime/LAmB, now narrowed to Cefepime + afebrile 24h

Duration of Cefepime?
#IDTwitter #IDMedEd #IDFellows
Today’s #tweetorial is on fever + neutropenia!

Background:
Up to 50% pts with solid tumors & >80% pts with hem malignancy will develop fever during chemo cycle assoc’d with neutropenia
Only 20-30% of these identify clinical infection
Only 10-25% bacteremia
3/
The very basics:
🔹Here is the classic article from 1966 that demonstrated ⬆️susc to infection as neutrophils<500
🔹Freq and severity of infection inversely proportional to neutrophil count
🔹Risk of severe infection and BSI greatest at ANC <100
pubmed.ncbi.nlm.nih.gov/5216294/
Read 15 tweets
12 Aug
1/ Hey #IDFellows, here is a new #IDTwitter Tweetorial: 24F w/1 wk hx pharyngitis + 1d cough & SOB. VS T 39.3C, RR 23, SpO2 92%, HR 112. Exam with tonsillar swelling & erythema; L neck pain and swelling on palpation. CXR w/peripheral nodular opacities. Best empiric abx?
2/ Lemierre’s syndrome = #eponym for suppurative thrombophlebitis of the jugular vein. Often preceded by pharyngitis +/- neck swelling. Commonly associated with pulmonary septic emboli. Check these #NEJM Clinical Images:
3/ Most common organisms include Fusobacterium necrophorum >>> other fusobacterium > anaerobic streptococci. Fusobacterium necrophorum, an anaerobic gram-negative rod, seems to be distinctively adept at causing septic thrombophlebitis.
Read 11 tweets
11 Aug
1/
Thank you all for the enthusiasm! #WeAreID #IDTwitter #IDfellows

#IDTweetorial
36F w/ fever for 6 days after the day of returning from Manzini, Eswatini. Stayed there 15 days, visited rural fields. Also, weakness, myalgia, night sweats, sore throat

What is your approach?
2/
Many approaches possible.

Check out this amazing tweetorial by @BoggildLab


1⃣ Common things being common: In addition to RTI, gastroenteritis, SSTI, UTI/STI, DO NOT want to miss: MDRT (malaria, dengue, rickettsial infections, typhoid fever)
3/
Or this great video tutorial by @EvelynSongMD and @CPSolvers

clinicalproblemsolving.com/%20dx-schema-f…

2⃣Beware of transmissible infections➡️infection prevention: Ebola, Marburg, Lassa, TB, MERS, SARS, Influenza
Read 13 tweets
10 Aug
1/
First #IDtweetorial

65M w/persistent MRSA bacteremia on day 4 of Vancomycin. Last Vanc trough 18.7. MRSA is Vanco Susc.
Primary team asking to change therapy.

What would you do? (Poll)

Let’s review some of the evidence to guide our decision
#IDTwitter #IDfellows
2/
First, what is considered persistent bacteremia?
In a frequently cited study, bacteremia in pts w/MRSA IE lasted a median of 7d w/Vanco, w/ no unusual complications
This led to believe that slow clearance was usual for some cases of MRSA IE
bit.ly/2PDQ4wl
3/
However, recent studies have shown significant increased risk in mortality and metastatic complications after 3 days of bacteremia.
bit.ly/31D7bnJ
Read 13 tweets

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