Day #159 - Fever of Unknown Origin - The Return

Due to fun rounds time constraints -- will point you to my previous blogs on FUO -- here.

Day #153 - Pneumocystis (PCP) Redux

Today we heard a case of PCP pneumonia with a classic presentation. For those of you who will end up doing medical education -- you should start saving up cases during your residency that you can use as exemplars of diagnoses, management, or approaches -- especially if they have key teaching points or interesting imaging. This will also help you for when you are suddenly called upon to provide impromptu teaching.

I have previously blogged in detail about PCP here. This blog links to a number of other blogs and articles that are also useful.

Day# 146 - Two cases

We talked about a case of stroke in a young patient. An approach to stroke in a young patient is outlined briefly here.

The case turned out to be meningovascular syphilis.

Here is an interesting article on the history of syphilis and another which talks about whether or not Shakespeare himself was infected.

The second case was that of massive liver enzyme elevation with synthetic dysfunction. I have previously blogged about hepatitis here.

Day #145 - Pyogenic Liver Abscess

Today we heard about a great case of pyogenic liver abscess. I wanted to clarify a few points of discussion.

Pathogenesis (most common in blue):

• Ascention of pathogens up biliary tree
• Ascention of pathogens through portal circulation. Often in the context of an intraabdominal nidus of infection like diverticulitis. May be in context of septic portal thrombophlebitis
• Cyptogenic
• Direct innoculation from trauma or iatrogenic
• Hematogenous spread from systemic infection
• Direct spread from gallbladder infection

Pathogens

• Gpc - strep milleri and other alpha haemolytic strep.
• Gnr - ecoli and klebsiella. Anaerobes (which often won't grow in culture)
  

• Amoebic liver abscess
• Hydadid cyst disease (echinococcus)

Treatment:

Pyogenic - use emperic coverage that will cover most pathogens above - I.e. Pip/tazo or ceftriaxone/metronidazole. Narrow spectrum to culture results not forgetting anaerobes

Drainage - either IR or surgical -- "Never let the sun set on undrained pus"

Amoebic - metronidazole 750po TID x 10 days followed by luminocidal agent

Hydadid - Specialized surgical care.