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Travis Smith, DO Profile picture
@RosenelliEM
Sep 26, 2020 • 17 tweets • 7 min read • Read on X
Time for some #SpacedRepetition from @CPSolvers @DxRxEdu @rabihmgeha

Some chat recap #ClinicalPearls and bonus pearls from #VirtualMorningReport on Friday Sept 25th clinicalproblemsolving.com/morning-report…

Case by the brilliant @Rafameed Image
A 31-year-old M born and raised in Brazil w/ no PMH presented with a 3 mon history of worsening DOE, orthopnea, 7kg weight loss, abdominal distention, dry cough, and syncope

Base rate of disease for an ID case with @k_vaishnani and @Rafameed is very high
An interesting fact from @3owllearning : Depending on the clinical problems, the studies of disease probability for differential diagnosis often show 10 - 25% of cases are unexplained, even after careful examination and testing.
Isn’t everything from Brazil Chagas?

In using Brazil as buzzword, endemic infections - Chagas, Leishmaniasis, yellow fever, paracoccidioides, leprosy, toxoplasmosis, sporotrichosis, Zika

His occupation is fisherman.. a clue or red herring?
Syncope could be from Pulm HTN. Patients with pulmonary artery hypertension (PAH) typically present with dyspnea, fatigue or chest pain. journal.chestnet.org/article/S0012-…

Most of the stuff we are familiar with has cutaneous manifestations
fresh water bugs- schistosomiasis, pseudomonas, aeromonas, NTM (marinum, ulcerans, avium), legionella, leptospirosis, naegleria

Here is a great case on SSTI from the water
But what about schistosomiasis causing portal HTN?
researchgate.net/publication/21…

Tricuspid regurg leading to liver failure⏭️to ascites causing abdominal distention
We have some interesting PE findings:

Auscultation showed a holosystolic murmur located at the left lower sternal border that augmented with inspiration. Auscultation also revealed a loud pulmonic component with a fixed split S2 combined with a right ventricle S4 gallop.
schistosomiasis is related to 1st group pulmonary hypertension

Here is a great one on PAH from @DxRxEdu

Outside of US, schistosomiasis the most common cause of Group 1 pHTN

is the fixed splitting of P2 from an ASD + Eisenmengers?

His abdominal exam shows hepatosplenomegaly and + hepatojugular reflux, 2+ LE edema
Accumulation of ascites in patients with RV failure can be due to high venous pressure reflecting back in the thoracic duct, slowing lymph drainage from the abdominal cavity through the cysterna chili.

Is there a BNP? would help to differentiate cardiac Ascitis with saag >1.1
Paracentesis shows a high SAAG of 1.4

SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid)

The Serum Ascites Albumin Gradient (SAAG) defines presence of portal hypertension (does not differentiate cause) in patients with ascites.
SAAG > 1.1 g/dL indicates portal hypertension is the cause of ascites with 97% accuracy.

mdcalc.com/serum-ascites-…

His CBC shows 15% eosinophils

A CT chest shows bilateral Pulm emboli, enlarged pulm vein

ECHO shows normal EF and mod TR with ⏫ Pulm press of 88
How do we tie all of this together?

THe emboli aren’t a perfect fit, but with eosinophilia, age, location, pHTN, really fits schistosomiasis well

Could the pulm filling defects be egg emboli.... Image
Serology showed Schistosoma Mansoni

Here is nice review ncbi.nlm.nih.gov/pmc/articles/P…

He was treated with Prizaquental and sildenafil and he improved

How did this happen?
The eggs went to the portal vein causing periportal fibrosis ⏭️ shunting blood into pulm vessels ⏭️ eggs dislodge into pulm vascul ⏭️ granuloma formation causing pulm htn and all his symptoms

Case closed!
Check out this article by @DxRxEdu @rabihmgeha @Gurpreet2015 A Tough Egg to Crack

journalofhospitalmedicine.com/jhospmed/artic…

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More from @RosenelliEM

Travis Smith, DO Profile picture
May 30, 2021
Some cool #Syphilis Pearls from an article that @k_vaishnani shared ncbi.nlm.nih.gov/pmc/articles/P… Primary syphilis first manifests into a painless chancre at the site of inoculation 1 to 6 weeks later…
Hematogenous dissemination then can occur typically 4 to 10 weeks later, giving rise to secondary syphilis. <40% of pts w/ syphilis have primary syphilis diagnosed. These “Secondary” lesions last for several weeks before spontaneously resolving. Coined “early, latent infection”
What does late infection mean? When syphilitic lesions recur after 1 year from the initial eruption, or seropositivity is detected more than 1 year after the initial eruption, it is termed late latent syphilis.
Read 5 tweets
Travis Smith, DO Profile picture
May 29, 2021
Some optics neuritis pearls in a short #Medtweetorial 🧵…. We all know that optic neuritis is frequently associated with multiple sclerosis (MS). But optic nerve inflammation can exist from autoimmunity, infection, granulomatous disease, paraneoplastic disorders, & demyelination Image
Classical ON from MS is unilateral, moderate, painful color vision loss with an afferent pupillary defect & normal fundus examination.
In those with ON, 95% of patients showed unilateral vision loss & 92% had associated retroorbital pain that frequently worsened w/ eye movement.
Read 14 tweets
Travis Smith, DO Profile picture
Oct 1, 2020
If you have not listened to the @CuriousClinPod most recent podcast (Episode 10: Why does metronidazole treat both bacterial and parasitic infections?) then I suggest you tune in.

curiousclinicians.com/2020/09/30/why…

I'll summarize their show notes here in short #medtweetorial
First a question:

Was metronidazole first used as an antibiotic or as an antiparasitic?
If you guessed antiparasitic, then you would be correct!

It was developed in the 1950s to treat the parasite trichomonas & then was used in the 1960s to treat other parasitic infections, like giardia and amoebiasis.
Read 14 tweets
Travis Smith, DO Profile picture
Oct 1, 2020
When you order a serum alcohol level, what does the lab measure? An answer and a quick #Medtweetorial on false elevations in #ETOH
If you guessed NADH, you would be correct.
Most lab assays for serum alcohol utilize a reagent containing alcohol dehydrogenase & NAD+

This is used to convert all present ethanol to acetaldehyde

Thereby reducing present NAD+ to NADH.
Read 11 tweets
Travis Smith, DO Profile picture
Sep 26, 2020
A Teal pain in the neck:

Follow along for a short #medtweetorial on #CervicalArteryDissection

or see the full handout here emboardbombs.com/s/Cervical-Art…

from @EMBoardBombs @blakebriggsMD @IltifatMD
This review will focus on spontaneous dissections, not traumatic, as well as the pathophys, risk factors, presentation, diagnosis, and management.

Cervical artery dissections are a common cause of stroke in young(<50 years )w/ some reports of up to 20% being from dissections
Much like aortic dissections, there is some loss of structure along the wall of either the internal carotid artery or vertebral artery

This allows blood to collect within the intima.

In patients <50 years old, cervical artery dissections account for 20% of ischemic strokes.
Read 24 tweets
Travis Smith, DO Profile picture
Sep 22, 2020
We didn't have a #Neuro case today on @CPSolvers #VMR with @AaronLBerkowitz but don't worry! Let's recap a prior episode for some #SpacedLearning @DxRxEdu @rabihmgeha

With @ddeng_22 @KannuBansalMD

clinicalproblemsolving.com/morning-report…
A 26 yo M w/ a PMH of nodular sclerosing hodgkins lymphoma p/w left-sided facial droop, L arm weakness, and dysarthria.

He presented 12 hours after onset and his symptoms had resolved.

3 months prior he had an autologous stem cell transplant and is currently on Brentuximab.
First of remembering that E=MC2

Time of onset and localization

Sudden Onset: Think stroke, seizure, Todd's paralysis, toxic metabolic, migraine with aura

Localization: Brainstem ipsilateral face and contralateral body
Read 24 tweets

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