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Ann Marie Kumfer

6 Nov, 9 tweets, 4 min read

@CPSolvers

1/Recapping some teaching points from @CPSolvers VMR today to keep me from refreshing NYT and 538 every 2 minutes. Thanks to @Flower_freeland for presenting an awesome case today.
clinicalproblemsolving.com/morning-report…

2/ Case: A 28yM diagnosed w/uveitis about 4-5 weeks prior p/w N/V, weight loss, diffuse weakness. Most uveitis is anterior involving the iris (iritis). Anterior usually painful (front of eye in innervated). Infections commonly unilateral, autoimmune may be bilateral

3/ Up to 50% of anterior uveitis is HLA-B27+. Lymphoma is an important mimic. Because the patient is from Vietnam, TB is the first thing that came to my mind. With TB, you should also thing of histo (and other funi). Knowing an immune status is important is working-up infection

4/Infectious causes of CNS disease & uveitis: Viral HSV, CMV, West Nile, HTLV-1, AIDS, SSPE, bacterial: bartonella, Whipple's, TB, leprosy, lyme, syphillis, ProtozoaL toxoplasmosis, PJP, parasite: gnathostomiasis (especially since patient from Vietnam) ncbi.nlm.nih.gov/pmc/articles/P…

5/ I do not focus on autoimmune disease as much here, but the below podcast has a great overview on autoimmune disease and the eye.

healio.com/news/rheumatol…

6/ PE showed white plaque on tongue, ptosis L eye, and ⬇️ muscle strength. Labs w/ lymphopenia (ALS 670), Na 128, HIV +. No CD4 count available. ALC correlates w/ CD4, ALC <1200 has +PV of 100% for CD4 <200 in HIV in 1 study but insensitive (NPV 32%). pubmed.ncbi.nlm.nih.gov/15477187/

7/MRI w/ scattered ring enhancing lesions. In HIV pts with multiple CNS ring-enhancing lesions, + toxo IgG, and compatible syndrome 90% probable dx is toxo. PCR is less sensitive. CNS lymphoma can have multiple lesions as well.

@Estefroide

8/@Estefroide also shared this great mnemonic for ring-enhancing lesions:
D: demyelinating disease (incomplete rim)
R: radiation necrosis or resolving hematoma
M: metastasis
A: abscess
G: glioblastoma
I: infarct, inflammatory, infectious
C: contusion
A: AIDS
L: lymphoma

@AnnaBriker

9/ Results of LP w/ 12 WBC (90%L) & multiple - inf w/u presumptively diagnosed w/ toxo (serology not available). Thanks @AnnaBriker and @RobWeberMDPhD for the great discussion. Always enjoy throwing thoughts (and zebras) around with @k_vaishnani & @TheRealDSrini in the chat.

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Ann Marie Kumfer

@AnnKumfer

8 Nov

1/ #tweetorial Next on the skeptical diagnosis series, I wanted to address cellulitis. I always feel a little angst when I am called to admit a patient w/ cellulitis. Does the patient really have cellulitis? In what % of pts diagnosed with cellulitis is the diagnosis incorrect?

2/ Here, I will focus and diagnosis and mimics. I plan to discuss mng of cellulitis later. Studies show that in 30-33% in patients diagnosed with cellulitis, the diagnosis is incorrect.

3/ Of those with an incorrect diagnosis, around 85% percent do not need hospitalization and 92% did not need antibiotics. Misdiagnosis is associated with millions in increased healthcare costs and up to 9000 nosocomial infections.
pubmed.ncbi.nlm.nih.gov/27806170/
pubmed.ncbi.nlm.nih.gov/29453874/

Read 15 tweets

Ann Marie Kumfer

@AnnKumfer

20 Oct

#medtwitter 1/What are the top three diagnoses of which you automatically skeptical? My top 3 are UTI, cellulitis, and CAP. Before talking more about "UTIs:, I must repeat the mantra:
PYURIA DOES NOT = UTI.
I will focus mostly on pyuria

2/ Let's consider the following scenario: A young female comes in fever. Urinalysis is obtained that shows 10WBC, - nitrite negative. Boom! You have diagnosed UTI, done. Just kidding, if only it was that easy.

@thecurbsiders

3/I highly suggest listening to the @thecurbsiders episode on UTI (thecurbsiders.com/podcast/231). An important point they make is that UTI is bacteruria + signs and symptoms that localize to the urinary tract. Bacteruria alone is not enough for treatment.

Read 15 tweets

Ann Marie Kumfer

@AnnKumfer

13 Sep

1/ #medtwitter #tweetorial Raise your hand if you have ever inappropriately checked an ammonia level.🙋
1. Why is ammonia ⬆️ in liver failure and how is this connected w/ encephalopathy?
2. When should levels be checked?
3. Aside from cirrhosis, what other conditions ⬆️ammonia?

2/ Ammonia is primarily produced by bacteria w/ urease enz in intestines but is also produced in muscle and the kidneys.

Table source: ccjm.org/content/76/4/2…

3/ 85% of ammonia is cleared by the liver through the urea cycle. 15% is cleared by muscle/kidneys. If the ammonia (/other nitrogenous waste) not metabolized it passes through the blood brain barrier glutamate>glutamine> astrocyte swelling and free radicals>encephalopathy.

Read 19 tweets

Ann Marie Kumfer

@AnnKumfer

2 Sep

@UnremarkableLab

Really enjoyed @UnremarkableLab last night where we discussed HTN in the hospital.
You are an intern on night float and get called that a patient's BP is 195/110. You:

For anyone who participated, I found this article a really helpful read. I also would suggest listening to the Annals of Call Podcast(acpjournals.org/doi/10.7326/A1…).

the-hospitalist.org/hospitalist/ar…

Some key points the article made:
1. 72% of pts in hospital have HTN
2. 1 study the article cites- 94 pts given IV hydral (only 4 needed)>17 had adverse effects from hypotension
3. Study of pts given IV treatment for HTN- 56% had BP ⬇️ >25%, 2 hypotensive, 6 had to hold BP med

Read 10 tweets

Ann Marie Kumfer

@AnnKumfer

1 Sep

What infections are on your list for infection-induced thrombosis? Why do infections predispose to thrombosis?

Source: ncbi.nlm.nih.gov/pmc/articles/P…

Here are some:
Bacterial: H. pylori, C. pneumoniae, M. pneumoniae, H. influenzae, S. pneumoniae, S.aureus, E.coli, Fusobacterium species, C burnetii
Vital: COVID-19, Influenza, EBV, CMV, HSV, VZV, HIV, Dengue, Hep A/C
What infections do you think of?
williams.medicine.wisc.edu/viral_coagulop…

The below infections are associated w/ antiphosholipid antibody + (likely through molecular mimicry), but not all infections significantly increase thrombosis risk. Risk ⬆️in HIV, Hep C, and CMV. Also ⬆️ risk with genetic predisposition. Image source: ncbi.nlm.nih.gov/pmc/articles/P…

Read 15 tweets

Ann Marie Kumfer

@AnnKumfer

15 Aug

11/ What if instead the pred dose is 7.5mg ? Should pt be given stress dose steroids? A JAMA review found in in patients on chronic steroids (pred doses 5-16mg) who received their usual daily dose of steroid on day of surgery, no cases of hypotension. pubmed.ncbi.nlm.nih.gov/19075176/

12/ Who should be given stress-dose steroids and how much should be given?
1. Pts w/ adrenal insufficiency on physiological dose of steroids
2. Consider if receiving major surgery (ie cardiothoracic surgery or major abdominal surgery)

Table source: pubmed.ncbi.nlm.nih.gov/11779267/

13/Caveats:
1/If a patient is unable to take oral dose of steroid prior to surgery or concern for absorption, give IV formulation
2 Giving IV hydrocort in above scenario likely be sufficient to meet physiological cortisol need but easier to keep on oral dose if tolerating PO.

Read 5 tweets

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