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Oct 12, 2020 • 4 tweets • 2 min read
Kicking off this Monday w/ some UpToDate points on 💨CRYPTOGENIC ORGANIZING PNEUMONIA (COP)💨, a new diagnosis I encountered on #pulm last week uptodate.com/contents/crypt…
COP is categorized as one of the Idiopathic Interstitial Pneumonias group of ILDs. It was formerly called Bronchiolitis Obliterans Organizing Pneumonia (BOOP), but renamed due to features more consistent w/ inflammatory pneumonia vs. primary airway disorder. Figure: @DrEricStrong Image
COP is "cryptogenic" b/c the entity represents an unresolved pneumonia, & "cryptogenic" b/c etiology is unknown. The suspected pathophys is alveolar epithelial injury ➡️ fibroblast recruitment & fibrin formation w/i the alveolar lumen.
Correction: COP is "organizing" b/c the entity represents an unresolved pneumonia . . .

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More from @ASanchez_PS

Andrew Sanchez M.D. Profile picture
Apr 11
ILD clues for the internist: here's a 🧵with some quick hits!

Framework by @DrEricStrong:



1/12 Image
Exposure-related ILD:
🫁 Hypersensitivity pneumonitis: look for "head cheese sign" & centrilobular nodules in patient w/ exposure(s)
🫁 Pneumoconioses
🫁 Radiation pneumonitis
🫁 Medication-induced

"Head cheese" = high (GGO) + low (mosaic) + normal lung attenuation

2/12 ImageImage
ILD 2/2 Connective Tissue Diseases
🩸 Scleroderma: most common to cause ILD (usually NSIP)
🩸 RA: ILD is most common pulmonary manifestation
🩸 Lupus: least common to cause ILD

NOTE: many radiographic & histopath patterns possible!

Ref: tinyurl.com/5cv4btuj

3/12 Image
Read 12 tweets
Andrew Sanchez M.D. Profile picture
Mar 30
🧵 of favorite Endocarditis notes compiled!
Elegant overview of differing presentations of Infective vs. Non-infective endocarditis by @CPSolvers.

Note: often no symptoms of non-infective endocarditis until embolization (eg stroke, mesenteric ischemia, renal infarcts) or valvular dysfunction (eg CHF).
Endocarditis Complications:
♥️ Embolization +/- mycotic aneurysms
♥️ Intra-cardiac abscess +/- heart blocks
♥️ CHF via valvular dysfunction

Note:
♥️ If suspicion for embolic stroke, it's prudent to add CNS vascular imaging to assess for CNS mycotic aneurysm. CONSULT NEURO.
Read 10 tweets
Andrew Sanchez M.D. Profile picture
Mar 25
Approach to a (+) Rheumatoid Factor (RF)!

As we've all heard, RF is poorly named because (+) RF does not always = RA.

So, what is RF?
RF = IgM antibodies against Fc portion of IgG.

Thankfully, the mechanism of RF production allows the development of a nice diagnostic framework!
Vastly oversimplified, this is the mechanism for RF production:

Abnormal immune response (from rheumatic *or* chronic inflammatory disorder)

👇

Chronic antigen stimulation (from chronic infection *or* malignancy)

👇

RF production
Read 11 tweets
Andrew Sanchez M.D. Profile picture
Mar 11
Peripheral edema + *no* intra-thoracic edema + normal LVEF does not always= isolated R.-sided CHF.

Other major culprit? HFpEF!

Why?

First, ⏫ LVEDP (>15 mmHg) causes pulmonary venous HTN...
Pulmonary venous HTN results in PA vasoconstriction & a sustained increase in mPAP. This ultimately causes ⏫ RVEDP via high afterload, often w/ RV systolic dysfunction.

The reflex PA vasoconstriction allows right-to-left forward flow in the face of high LVEDP:
High RVEDP causes ⏫ RAP & CVP, which initially causes peripheral edema.

Once LVEDP & pulm venous pressures are roughly >18 mmHg, you see interstitial edema, followed by pulmonary edema at >25 mmHg.

If sustained, b/l pleural effusions begin to accumulate, followed by ascites.
Read 5 tweets
Andrew Sanchez M.D. Profile picture
Feb 9
Compendium of ECG findings concerning for ☠️♥️occlusive MI ♥️☠️ (1/11)
First, back to basics & traditional STEMI criteria! Here's a nice figure of Lead Anatomy. I saved this forever ago, so not exactly sure of the source ¯\_(ツ)_/¯

(2/11)
STEMI criteria is met if: STE at least 1mm in 2 contiguous leads, but with higher cut-offs in V2-V3, & with addition of new LBBB in setting of compatible clinical picture. You can localize the coronary lesion using the leads affected! Localization chart by @DrEricStrong (3/11)
Read 13 tweets
Andrew Sanchez M.D. Profile picture
Oct 7, 2020
Today on #pulm consult one of my new patients came in with a history of sputum (+) for a NON-tuberculous mycobacterium, specifically, M. avium complex (MAC)! Never worked this up, so let's talk about 🗣️ Pulmonary disease in MAC 🗣️ uptodate.com/contents/overv…
First, some review. NON-tuberculous mycobacteria (NTB) are mycobacterial species other than TB & M. leprae. NTB are found kind of everywhere. The fact NTB is actually a frequent lab contaminant in conjunction with...
...the fact most lung disease caused by NTM is indolent, and the fact (+) sputum cultures may represent benign respiratory colonization makes the diagnosis of true pulmonary NTB infection tricky.
Read 17 tweets

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