38/M w/ progressive loss of scalp, axilla, and chest hairs. Recently dx w/ HIV 6 mos ago when he developed dissem cryptococcosis. He has now been taking TDF/FTC, raltegravir, TMP/SMX, azithromycin, & fluconazole x 6 mos. Drug-induced alopecia is suspected. Most likely culprit? 1/8 Nice job! 52% got the right answer, fluconazole.

In animals/humans, fluconazole has been shown to induce telogen effluvium bit.ly/2MMnF9j, one of the most common causes of nonscarring hair loss (see Table 👇 bit.ly/38rTXyN).

@LParraRod @NNolanMD

32/M, h/o HSV encep 1 mo ago (s/p 21 d ACV), on ceftri/metronidazole for sacral OM, p/t ER +delusion, fever, seizure. CSF: WBC 25 (L>N), ⬆️TP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
b/l temporal lobe enhancement ⬆️ from prior. Whch of the ff is the best Tx for this condition? 1/11
The group is split b/n steroids & d/c metronidazole. The answer here is Tx w/ steroids. Indeed, this is a case of autoimmune post-HSV encephalitis (anti-NMDA receptor encephalitis post-HSV). Good job @LemuelNonMD
@LeMiguelChavez @adilrashid83 @Orchid10Tree @KhalafSuha

67/M w/ poor control DM, BPH, +10 d dysuria. T38.1, BP 120/80, +tender R CVA. WBC 14. U/A: 21 WBC, UCx: (-)bacteria, +Candida glabrata (fluc-R) x 2 samples. BCx(-), CT: +prostate hypertrophy. Has had no response to ceftriaxone. Has no Foley cath. Which of the ff is indicated? 1/15
The vote is split b/n micafungin and ampho deoxycholate! Thank you for all your responses!

Although micafungin may be a reasonable option, the correct answer here is ampho deoxycholate.

In this tweetorial, we will talk about Candida UTI and its treatment.
@ID_fellows

ID Miscellany|physical Exam|Signs|Humanities #idmesh
1/20
𝙁𝙀𝙑𝙀𝙍 𝙋𝘼𝙏𝙏𝙀𝙍𝙉𝙎: 𝘼 𝙇𝙊𝙎𝙏 𝘼𝙍𝙏?

Great! Three quarters find inquiring about fever patterns still useful. We will review some of the most important fever patterns.

@ID_fellows

https://twitter.com/WuidQ/status/1305649807395033088?s=20

2/20
For centuries, physicians have relied upon meticulous observations to dx infections. For many years, observation of the fever pattern provided physicians w/ important diagnostic clues. However, the advent of abx & advanced dx & imaging has changed this landscape. #idmesh

29M w severe persistent asthma p/w recurrent exacerbations despite optimal LABA/intranasal steroids. Abs eos 1250, total Ig E 1500, CT +mucus plugging, central bronchiectasis upper-middle lobes. Originally from Mexico, now in Texas. Which of the ff tests is indicated? 1/10
Great job! The majority got the right answer, allergic bronchopulmonary aspergillosis (ABPA).

Recurrent asthma exacerbations despite optimal asthma therapy & eosinophilia a/w mucus plugging and multilobar central bronchiectasis should raise suspicion for ABPA.

48M +cirrhosis, underwent routine large volume paracentesis. +Abd fullness, (-)fever, abd pain/tenderness, confusion. Ascitic fluid: light yellow, 100 PMNs, SAAG 1.5, Cx +pan-susc E. coli. WBC 8, Crea 0.8, bili 1.8. Which of the ff is best management for this patient? 1/5
Only 21% got this right: no abx, repeat para in 48H.

The dx of spontaneous bacterial peritonitis (SBP) rests on finding >/= 250 PMNs/mm3 in the ascitic fluid. Most patients with SBP are symptomatic (only 13% with no symptoms bit.ly/3gp5nEU)

28/F, 38 wks pregnant G2P1, in clinic w/ dysuria. Labs u/r exc urine Cx + pansusceptible E. coli. Denies fever. No CVA tenderness. No PMH or allergies. Which of the ff adverse events to the baby makes nitrofurantoin contraindicated in this patient? 1/5
The majority got the correct answer - hemolytic anemia.

Nitrofurantoin use during pregnancy is category B (no evidence of risk in studies). Hence, it is one of the options for the Tx of asymptomatic bacteriuria among pregnant women.

#idgrandrounds
Presented by @LParraRod
1/2
Man in his 60's, on-going temozolamide + dexa for glioblastoma, p/w 1 wk b/l knee arthritis, preceded by 4 d fever & watery diarrhea.

H/o DLBCL in remission x 4 yrs, mild b/l knee OA
Recently stopped TMP-SMX for unclear reason. 2/2
Immigrated to the US from El Salvador 20 yrs ago. No recent travel, pets, illicits. Lives in IL.

WBC 3.6. CMP u/r
Synovial fluid: WBC 85K (80%N)

Approach, DDx? @TxID_Edu @CarlosSaldana @k_vaishnani @VarunPhadke2 @UAB_ID @BIDMC_IDFellows @IUIDfellowship @LeMiguelChavez

70/M Midwest US, back ache x 2 mos.
PMHx: DM, Rx Bladder cancer before. No travel/exposures.

MRI: T-L discitis/osteomyelitis.

Bone bx: granulomatous inflam. AFB stain+. PCR + for M tb complex.
AFB cx : Mycobacteria +, S to Rif & INH, R to PZA.

Likely risk for his infection? Ans(1/6): Great Job 👏. The majority recognized this as a complication of intravesical BCG immunotherapy for the Rx of bladder cancer.
-BCG a live attenuated strain of Mycobacterium bovis (M. bovis BCG)
-infectious complications ( local or systemic) occur in 1-4%

#WuidQchronicles
1/12
Exactly 2 yrs ago, we sent our 1st Tweet👇 & the rest is history. It’s the 1st of its kind that brought together the power of Twitter & the science of test-enhanced learning in ID #MedEd.

https://twitter.com/WuidQ/status/1019255397776023552

2/12
Our 1st tweet was about syphilis (leutic hepatitis)☝️and since then, we’ve talked about syphilis many many times! Thank you to our guru @hrenoID for your expertise!

▪️We talked about congenital syphilis in Gerard de Lairesse’s portrait👇

https://twitter.com/WuidQ/status/1128297551726297088

Part 1/2 📌
32/M w/ 6 wks fever, abd pain, weight loss. Exam: tender RUQ, hepatomegaly. 🧪: WBC 3.1, Hgb 8, Plt 110; AST 62, ALT 70, Alk Phos 450, bili 0.8; RPR(-). HIV came back +, CD4 89. CT: scattered tiny heterogenous liver lesions. Path shown👇[Go to next tweet] Part 2/2 📌 [case continued]
Path shown👆: multiple dilated blood-filled spaces surrounded by clumps of Warthin-Starry+ rods, AFB stain (-). Lives in Florida, no travel, previously healthy, worked as a cashier, no pets. What is the most likely opportunistic infection?

𝗜𝗗 𝗖𝗼𝗿𝗲 𝗧𝗼𝗽𝗶𝗰𝘀 𝟭 #idcoretopics
1/20

TICKBORNE INFECTIONS (TBI)

It’s summer (= tick bites 🐞) and we have new faculty, fellows, residents, interns, & students coming from different places.
@grepmeded

This tweetorial is an overview of TBI mainly in the US. 2/20

▪️Climate change is expanding the seasonal/geographic distribution of TBI.
▪️Lack of tick bite in H/P should not dissuade you from considering TBI. In fact, only ¼ with Lyme remember a tick bite.
▪️No perfect test.
▪️Early Abx is important.

#idcoretopics

[Part 1/2] 63M w 3 mos L breast enlargement, pain/redness👇,+fatigue. Exam: tender, no nipple discharge, no rash or regional lymphadenopathy. Labs: U/R. Mammogram: thickened areola/nipple. Biopsy: dense lymphocytic infiltrate in dermis, no malignancy. [MCQ in Part 2, next tweet] [Part 2/2] Path Gram/GMS/AFB & Cx (-). 14d Bactrim - no relief. 6 most ago, immigrated to the US from Norway where he was a hunter. Owned livestock, +tick/arthropod bites. Remote h/o treated latent TB. Which of the ff is the most likely cause?

26 /M,Arizona, PMH of coccidiodal meningitis on fluconazole x 2yrs, was recently dx with LTBI and Rx with Rifabutin.
1m later-> abrupt R eye pain with decreased vision.

Opthal exam- acute anterior uveitis with hypopyon
No systemic symptoms
Cocci serologies (-)
Likely cause ? Ans (1/3): The majority got it right. Congrats! The question stem pointed to rifabutin induced uveitis. The uveitis is usually anterior, begins unilaterally and progresses to involve both eyes and commonly associated with a hypopyon!

Part 1 of 2
19M +3 wks fever, confusion. Exam notable👇. Brain MRI +frontal lobe masses. CSF: lymph pleo, low gluc. CSF/blood cx, viral PCRs, Histo/Crypto/Blasto/Cocci(-). IGRA/AFB smear/Cx (-). Brain bx: granuloma, +necrosis, AFB/GMS/Cx(-). No response to Abx. 👉 Part 2 Part 2 of 2
Previously healthy, no PMH exc for recent dx of “skin TB” when he p/w nasal skin lesion 👆that showed granuloma w/ (-)AFB/GMS on skin bx. Started on RIPE 2 mos prior to presentation. Lives in rural Minnesota, (-)travel. Given SSx, w/c of the ff is the most likely Dx?

Part 1/2
19/M fr Colorado +5 d fever, sudden-onset SOB. ER: 38.7, 60/40, 84%RA. Intubated. CXR +pulmonary edema. WBC 38K (60% N w/ marked immature cells, +atypical lymphs), Hgb 14/Hct 60%, Plt 78, ALT 90, n/l bili. Blood, BAL Cx’s (-), COVID, flu(-).

MCQ, exposures in Part 2/2 Part 2/2 case continued..
2 wks ago, was renovating a rodent-infested house in a farm that grazed cattles. 1 wk ago, +tick/mosquito bites during a hike. Also reported his roommate had fever/cough a few days prior. What is the most likely source of transmission of this infection?

1/3
Sorry guys for the short hiatus. But I’m back! Let’s start with an #idgrandrounds case (as always, patient info modified for privacy)

👉 36/M w/ HIV, p/w GTC seizure. No prodrome. No fever, chills, headache, vision changes

@LeMiguelChavez @NNolanMD @Jncherabie @arauseomd 2/3
2 mos ago, admitted +confusion. That time, CD4 40, VL 4M. Extensive w/u (-): n/l brain MRI, LP (0 WBC, n/l TP/gluc), (-)ID w/u including crypto, JC, EBV, CMV, Toxo. Toxo IgG(-). CT: n/l. ART started

Current admission:
Exam: T 37. Somnolent, no deficits.
Labs: CD4 380, VL 7K

20 yr/M athlete, hx of CGD on TMP/SMX prophy p/w acute onset SOB + cough x 2d . O’wise well, recent gardening+ . Intitial CXR (N)

Rapid prog. in 2d needing ventilation. CXR with b/l diffuse infiltrates .
Bcx: (-)
BAL: PJP DFA & COVID-19(-), Cx :A fumigatus +

Treat? Ans 👏 many recognized "Fulminant Mulch Pneumonitis" with invasive aspergillus.

-among genetic immuno def's, CGD is the only one assoc. with invasive fungal infections in the absence of preexist. lung damage
-single greatest cause of mortality in CGD
-usually insidious

28/F fom Bolivia, no PMH, referred to you for a +Trypanosoma cruzi serology. No SSx, has normal EKG (w/ 30 sec strip), CXR & echo. Which of the following complications of Chagas’ disease has the most evidence to support treating her with benznidazole to reduce risk? 1/14
Only 1/3 got the correct answer: vertical transmission.

Although most patients with indeterminate Chagas are treated w/ benznidazole, there is limited data on the effect of Rx to progression to cardiomyopathy/GI involvement (partly because it requires decades of ffup).

#idgrandrounds
1/2
32 F w multiple sclerosis on rituximab, +10d fever, R knee pain in December. Had dysuria tx w/ TMP/SMX 1 wk prior. No trauma. Exam: swollen/tender R knee. No rash. Purulent synovial fluid: 60,000 cells 70%N. Multiple synovial/blood bacteria/fungal/AFB Cx (-) 2/2
No response w/ cefe/vanc. GC/CT(-), HIV(-), Q/Brucella(-), fungal studies(-).
Lives in rural IL, no travel. Denies substance use. Single, sexually active w/ 1 partner. No pets. Unemployed.

Thoughts & DDX? @VarunPhadke2 @TxID_Edu @k_vaishnani @Cortes_Penfield @jdcooperid

32M fr Mexico +jaw/abdominal pain x2 days. No fever,diarrhea,N/V. Exam: +trismus, rigid abdomen, +bandaged laceration R arm. Labile BP/HR, +sweating. No PMH/meds. Vaccine status unknown. W/c of the ff can be adjunctively used to treat spasms & autonomic dysfxn a/w this illness? 1/9 A third got the right answer, magnesium. The case described in the MCQ is a patient w/ generalized tetanus, the most common form of tetanus.

Mg, which is used in the management of eclampsia, acts as a presynaptic NM blocker that also inhibits catecholamine release.