A middle aged woman w/ PMHx Bipolar, HLD, and hypothyroidism who p/w syncope in s/o 2-3 months of LE ecchymoses/petechiae, admitted for syncope, anemia, and petechial rash ultimately diagnosed with scurvy.
Key Learning Points
-Vitamin C deficiency results in impaired collagen synthesis – typical pathologic manifestations occur in collagen-containing tissues/organs: skin, cartilage, dentin, osteoid, and capillary blood vessels – scurvy may present with gum bleeding, petechiae or ecchymoses
-The skin findings may initially resemble a vasculitis!
-Treatment is vitamin C supplementation – many of the constitutional symptoms improve within 24 hours – bruising and gingival bleeding resolve within a few weeks
An eldely man with a hx of hypothyroidism, recent L TKR and a hx of DVT 1 year prior who was called to come to the ED for a heart rate in the 130s found to be in new afib.
Key Learning Points
*Don’t treat subclinical hypothyroidism unless T4 is > 10 or thyroid antibody is +; the reason for treating subclinical hypothyroidism is risk of progressing to an overt hypothyroid state
*IV metop vs. PO Metop
-Per Kaiser Guidelines – oral beta blocker therapy is preferred over IV therapy in the setting of acute MI; oral administration should be initiated within the first 24 hours for MI patients who do not have any of the following (a) heart failure, (b) low output state, (c) increased risk for cardiogenic shock, or (d) other relative contraindications (PR > 240 msec, 2nd or 3rd degree heart block, active asthma or reactive airway disease). Early aggressive IV beta blockade can pose a net hazard in hemodynamically unstable patients.
*Number to transfuse in setting of ACS?
-The optimal transfusion threshold in the setting of ACS remains unresolved. In general transfuse when the Hgb is < 8 g/dL and consider transfusion when the Hgb is between 8 and 10 g/dL. Pilot trial of 110 patients with ACS demonstrated that a liberal transfusion strategy to raise the Hgb >/= 10 was associated with greater survival at 30 days
A middle aged man with fever, bone pain who presents after travel with thrombocytopenia, transaminitis, and AKI ultimately diagnosed with Leptospirosis.
*How do I factor in prophylaxis in a returning traveler?– know that malaria has A LOT of resistance – you need to know if the patient received appropriate prophylaxis for Falciparum in the region – Malarone (atovaquone and proguanil) is generally good for malaria prophylaxis. The Yellow Fever is a good vaccine
*Know the DDx for fever in a returning traveler: Malaria, Dengue, Chikungunya, Rickettsia, Scrub Typhus, Leptospirosis, Influenza, and Acute HIV
*This case was a very classic presentation for leptospirosis known as Weil’s disease-> liver damage (causing jaundice), AKI (tends to be an interstitial nephritis); and bleeding
*Most ricketssial disease have a dramatic response to doxycycline – also the drug of choice for leptospirosis if the patient does not have meningeal disease
*Geosentinel is a global surveillance network of travel medicine clinics that collect data from ill international travels.
A middle aged woman with a hx of severe bilateral glaucoma (legally blind), breast CA in remission who presented with acute proximal lower extremity weakness and subacute dysphagia admitted for statin-induced myositis due to elevated CK, eventually requiring intubation due to difficulty maintaining secretions, and found to have positive AQP4 Ab confirming the diagnosis of neuromyelitis optica.
- NMO is an inflammatory CNS disorder characterized by severe, immune-mediated demyelination and axonal damage mainly affecting the optic nerves, spinal cord, brain and brainstem. It is distinguished from MS by the presence of AQP4 antibody.
- Its incidence is 10 times higher in women than in men and more common in people of Asian, Hispanic, and African descent. Median age of onset is 32-41 years.
- Main clinical features include optic neuritis, acute transverse myelitis, area postrema syndrome.
- Evaluate with brain and spinal cord MRI, AQP4 Ab status, CSF analysis
- Diagnosis: Pt has at least one core clinical characteristic; enhancements on brain and spinal cord MRI; positive AQP4 IgG serum (and often CSF) autoantibody status; and exclusion of alternative diagnoses.
- Treatment: high dose IV methylprednisolone, plasma exchange, and immunosuppression treatment long-term disability and mortality rates are high
A middle aged man with stage IV HCC of unknown etiology who presented 2 weeks after biliary stent placement with confusion found to have E. Coli bacteremia.
**Learning point for Gram-negative bacteremia
-Treat presumptively with Zosyn – consider 2nd gram negative agent if: immunocompromised; high risk for P. aeruginosa, or unit antibiogram shows drug resistance > 20-25% for GNR pathogens
Risk factors for P. aeruginosa
-Current hospitalization or admission to an intensive care unit
-Recent P. aeruginosa infection
-Admission from along-term care facility
-Recent IV abx