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Nihar Ranjan Nayak

Jan 2 • 8 tweets • 4 min read

Mucormycosis:
1. Fatal invasive disease with high mortality
2. Genus: rhizopus, mucor, cunninghamella, lichtheimia etc
3. Risk factors: Uncontrolled DM, DKA, neutropenia, prolonged glucocorticoid use, elevated levels of free iron, SOT, HSCT, COVID-19 infection.

4. Rhino-orbital-cerebral disease: most common form, seen in diabetes, steroid use. Ethmoid sinus-->orbit-->frontal lobe/cavernous sinus, hard palate in advanced case.
5. Pulmonary disease: second most common, in organ transplant, chemotherapy receiving pt.

6. Cutaneous: hematogenous dissemination or direct inoculation. Can be highly invasive. Needs prompt debridement.
7. GIT: GI bleeding, fungating mass seen at UGIE, perforation, high mortality.
8. Disseminated disease: most common site is brain. Mortality >90%.

9. Dx: Bx with HPE is the most sensitive method. Broad aseptate hyphae with right angle branching is seen. Yield from culture is low.
10. CT shows sinusitis,MRI is more sensitive for orbital & CNS ds
11. Early initiation of liposomal Ampho-B (5-10 mg/kg) improves survival.

12. Surgical debridement is important for eradication.
13. Reversing predisposing conditions, treating underlying malignancy.
14. Posaconazole & isavuconazole are used for step-down & salvage therapy.
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Nihar Ranjan Nayak

@nihar_nayak2

Jan 2

Iron metabolism & IDA:
1. Transferrin (iron binding protein in plasma) has two iron-binding sites & exists in 3 forms: apotransferrin (not bound to iron), monoferric & diferric forms: diferric has the highest affinity for Tf receptors.

2. Developing erythroblasts have the highest number of Tf receptors
3. Normally adult male & female need to absorb 1 mg & 1.4 mg elemental iron respectively to meet needs
4. No regulated pathway of iron excretion, lost by blood loss or loss of epithelial cells.

5. Heme iron is most readily absorbed.
6. Hepcidin regulates iron absorption by controlling the activity of ferroprotein.
7. Erythroferron: Suppresses hepcidin level to increase iron absorption in states of erythroid hyperplasia.

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Nihar Ranjan Nayak

@nihar_nayak2

Jan 1

Aspergillosis (disease spectrum, Dx, Rx):
1. Refers collectively to all invasive and allergic disease caused by aspergillus species
2. A.fumigatus: causes most of the invasive & chronic aspergillosis & allergic disease
3. A.flavus: sinus, cutaneous infection & keratitis

4. A.niger: otitis externa
5. It's a hyaline, septate branching mold
6. Risk factors: neutropenia, glucocorticoid use, CGD, severe influenza or Covid-19, COPD, pulmonary TB, infliximab, ibrutinib use, ECMO
7. Invasiv: pulmonary, sinusitis, cutaneous, endocarditis, cerebral

8. Chronic pulmonary aspergillosis(CCPA) : single or multiple cavities in upper lobe, a/w fatigue, weight loss, hemoptysis, prior lung disease like TB etc, untreated can cause fibrosis & destroyed lung
9. Aspergilloma: fungal ball. A/w CPA.

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Nihar Ranjan Nayak

@nihar_nayak2

Dec 31, 2022

Necrobiosis lipoidica:
1. Chronic granulomatous disease
2. Commonly involve lower limbs: pretibial area most common
3. A/w T1DM, T2DM but can happen in non-DM also
4. Common in young, middle aged pt

5. Red-brown, yellowish papule or plaques that enlarge, undergo atrophy & form ulcers & telangiectasia
6. Bx: granulomatous dermatitis, inflammatory infiltrates
7. Rx: avoid trauma, topical & intra-lesional corticosteroid, topical tacrolimus, PUVA photochemotherapy

Source: UTD.

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Nihar Ranjan Nayak

@nihar_nayak2

Nov 5, 2022

Heparin induced thrombocytopenia (HIT) :
1. Risk with UFH>LMWH
2. Thrombocytopenia develops 5-10 days after exposure, may develop rapidly if prior exposure is there, rarely delayed for >2weeks
3. Incidence is around 1% in critically ill patients, overdiagnosis is common.

4. IgG antibody formed against heparin-PF4 complex-->activation of platelets-->thrombosis+thrombocytopenia
5. Venous thrombosis more common than arterial and lower limb thrombosis more common than upper limb
6. Adrenal vein, mesenteric vein thrombosis can occur.

7. When suspected, calculate the 4T score: 0-3 low risk, 4-5 intermediate, 6-8 high risk.
8. Low risk- continue heparin, consider other causes
9. Intermediate n high risk- stop heparin, start non heparin anticoagulation, screen for PF4 antibody by ELISA.

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