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4 Feb, 8 tweets, 4 min read
#medtwitter Can you have a completely normal CSF profile in autoimmune encephalitis? (answer forthcoming)
This table is from a 2019 review. Interestingly in LG11, IgLON5, and GlyR the majority have a completely normal CSF profile including oligoclonal bands. (ncbi.nlm.nih.gov/pmc/articles/P…)
What about MRI? In what percentage of autoimmune encephalitis is the MRI of the head normal?
This depends on type of encephalitis and time course but 8F-FDG PET/CT more sensitive:
1 study of anti-body specific autoimmune encephalitis- only 43% with abnormal MRI ncbi.nlm.nih.gov/pmc/articles/P…
Paraneoplastic limbic encephalitis- 83% abnormal MRI findings (pubmed.ncbi.nlm.nih.gov/14601695/)
NMDA encephalitis- abnormal MRI 33% (ncbi.nlm.nih.gov/pmc/articles/P…) some studies up to 50%.
LGI1 AE- 59% MRI findings
pubmed.ncbi.nlm.nih.gov/32581996/
TLDR: Between 20-66% of pts with normal MRI
EEG findings can be non-specific such as slow waves although a delta brush can be seen on NMDAR in 33%. EEG usually non-specific, sometimes with epileptiform discharges. (pubmed.ncbi.nlm.nih.gov/22933737/, pubmed.ncbi.nlm.nih.gov/31800465/, pubmed.ncbi.nlm.nih.gov/26240088/)
So, normal results of do not always rule out autoimmune encephalitis. Be sure to keep in on the differential.

Table source: ncbi.nlm.nih.gov/pmc/articles/P…
This is a great review table from the NEJM review article.

pubmed.ncbi.nlm.nih.gov/29490181/

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Ann Marie Kumfer Profile picture
16 Dec 20
1/#tweetorial coagulopathy in liver disease and the role of vit K

Thanks to all who responded to the poll.
2/ Pts with cirrhosis are at higher risk of bleeding d/t ⬇️ factors, right? Not necessarily. In cirrhosis, there are ⬇️ in both anticoagulant and procoagulant factors in the liver. Additionally, factor VIII and VWF are usually increased.
3/ INR is only measuring a small part of the coagulation cascade, the extrinsic pathway (Factor VII). Additionally, variceal bleed is driven by ⬆️ portal pressure primarily.
Read 7 tweets
Ann Marie Kumfer Profile picture
15 Dec 20
Do you give vitamin K to pts with cirrhosis presenting with elevated INR? I would love to hear your thoughts about the topic.
Here are a few questions about Vit K in cirrhosis I wanted to answer. Please post additional articles on the topics that you know of. Question 1: Is there proof that patients with cirrhosis are Vit K deficient?
3/ It is proposed that patients w/ cirrhosis are at ⬆️ risk for Vit K def. I could find very few studies about this. This study of pediatric pts w/ cholestatic liver disease had high prevalence, but very different pop from most adults w/ cirrhosis. pubmed.ncbi.nlm.nih.gov/19502999/
Read 19 tweets
Ann Marie Kumfer Profile picture
7 Dec 20
#tweetorial To obtain blood cultures or not to culture? This was inspired by the ? from @reverendofdoubt and @GermHunterMD reply.

A pt w/ a hip fracture on POD1 has fever of 100.8. HR 90, BP 110/75, SpO2 96% ambient air. No localizing symptoms. Do you obtain blood cultures?
2/My reflex when I hear fever is to order blood cultures. It’s not wrong to make sure, right? As a resident, I remember grumbling at the ED for not ordering cultures on that CAP patient. First, what are the harms of ordering unnecessary blood cultures?
3/ Aside from the cost, there is a high rate of contamination on blood cultures from 0.6% to over 6%. In conditions with a low pretest probability of bacteremia, this represents a large prob that a + culture is contamination. ncbi.nlm.nih.gov/pmc/articles/P…
Read 15 tweets
Ann Marie Kumfer Profile picture
8 Nov 20
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 Profile picture
6 Nov 20
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 Image
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
Read 9 tweets
Ann Marie Kumfer Profile picture
20 Oct 20
#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.
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

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