Day #322 - Enterococcal Endocarditis

This patient presented with stroke. This article reviews stroke in IE. This related article reviews the neurologic manifestations of IE.




An original article by Osler on IE!



Some key points:
Mitral Valve IE ~ 10% stroke rate
Mortality is high -- 35% in hospital 52% at one year
Early antibiotic therapy reduces neurologic complications


I have previously blogged about infective endocarditis (see here) including enterococcal endocarditis. The first post goes over the Duke Criteria.



Indications for Surgical Treatment of IE (Native Valve):

• Development of heart failure
• MR/AR with dilating LV, or development of pulmonary hypertension
• Fungal IE or that caused by highly resistant organisms (think of it in MRSA)
• Patients with heart block, cardiac abscess, abnormal chamber-chamber connections
• Recurrant emboli despite ABX
• Class IIb -- large vegetations

Day #320 - Hypercalcemia from Presumed Sarcoid

A great case today -- and some good topics were covered by the discussant.

1) Hypercalcemia (previously blogged here)

2) Hepatitis C and its complications including:
* Mixed cryoglobulinemia (image) which can cause a vasculitis
* Membranoproliferative glomerulonephritis (review here)
* Porphyria Cutanea Tarda
* HCV Associated Lymphoma

3) Sarcoidosis (from review)

"sarcoidosis is established on the basis of compatible clinical and radiologic findings, supported by histologic evidence [review] in one or more organs of noncaseating epithelioid-cell granulomas in the absence of organisms or particles"
"as a diagnostic tool, measurement of serum ACE levels lacks sensitivity and specificity"

---

Fascinating --> Evidence exists that sarcoidosis can be caused/exacerbated by HCV treatment with interferon.

Day #316 - Swine Flu

Today we heard a case of a patient with undelying Wegner's Granulomatosis who presented with several days of fever and cough. Her chest xray showed no infiltrate. The majority of patients with influenza will present with cough (90%) and fever (~70%). Headache, myalgias, arthralgias, fatigue are also common but seen in only 50-60%. There is a rational clinical exam on influenza here.

The nasopharyngeal swab revealed influenza, which was PCR confirmed to be "swine flu"

Influenza evolves by two processes. Antigenic drift, where small mutations occur over time in the surface molecules which gradualy cause waning immunity. This is the basis of seasonal influenza.

Antigenic shift invoves abrupt changes in the surface molecules, often as a conseuqnce of recombination with swine or avian lineages, into a strain to which few in the population are likely to have immunity. This leads to epidemic (and pandemic) influenza.

Treatment of Influenza:

• Supportive care
• In patients admitted to hospital/ICU or those with severe disease or severe undelying co-morbidities should receive antiviral therapy (also give to healthy people with less than 72h of symptoms)
• Oseltamavir (neuraminadase inhibitor -- blocks entry of virus into cell) --> available orally, circulating H1N1 are resistant, circulating H3N2 are likely resistant.
• Zanamavir (neuraminadase inhibitor) --> inhalational only, all are currently succeptible
• Amandadine (M channel inhibitor) --> blocks release of viral RNA into the cytoplasm from the lysosome. Available orally, most H3N2 resistant, many H1N1 succeptible.

I have previously blogged about influenza here, here, and here.

Day #315 - Sepsis with DIC

Today we discussed a great case of SEPSIS (focus of infection unclear) with associated DIC.

SIRS Criteria:
Fever or hypothermia
WBC >12,000 or less than 4,000
HR >90
RR >20


Sepsis = 2 or more SIRS criteria of presumed infective etiology
Severe sepsis includes sepsis with end organ dysfunction or lactate >4

Septic shock includes severe sepsis with refractory hypotension requiring inopressors
I have blogged about Early Goal Directed therapy here. Source control is as essential as broad spectrum antibiotics in the treatment of sepsis.

These are recent guidelines on the diagnosis and management of DIC here. Transfusion of plateletes and factors is limited to patients who are bleeding or at high risk of bleeding (i.e. post-op), therapeutic heparins are limited to patients who have thrombosis, DVT prophylaxis is required.

Day #314 - Pulmonary Eosinophilia

Very complex case facilitated by an expert discussant. The key focus, other than on the case at hand was a demonstration of clinical reasoning and Bayes theorem.

We highlighted the importance of Occam's Razor -- but stressed the importance of recognizing Hickam's dictum.

I have previously blogged about pulmonary eosinophilia here (with references). In my mind, an important consideration in this patient (given travel to China) is to exclude disseminated strongyloidiasis because like infliximab related interstitial lung disease (NEJM article here) 'strongy' can appear to improve on steroids.

This is a recent review from the Lancet on TNF-alpha blockade and the interaction with tuberculosis.

NB: Review of radiographic manifestations of pulmonary TB.

Day #306 - TB Pleuritis

We discussed a great case of tuberculosis causing pleural effusion today. I have previously blogged about this before.

Previous blogs on pleural effusion here and here (including discussion of Light's Criteria and parapneumonic effusions/empyema).

Modified Light's Criteria (see review here):

• Change LDH pleural fluid 0.45 ULN (increases sensitivity but reduces specificity)

Alternative tests:

• LDH (0.45ULN), cholesterol (45mg/dl) and protein (29g/L) of pleural fluid, done in combination have similar performance characteristics to Light's criteria and don't require paired serum samples.

Day #305 - HIV Lymphoma

Today we discussed a case of a patient with known HIV disease (CD4 300-500, not on therapy) who presented with fever, diffuse adenopathy, and splenomegaly. The presumed cause is lymphoma.









The differential diagnosis would include:

Infections:

• • HIV with high level viremia
  • Mononucleosis syndromes (EBV, CMV, acute toxoplasmosis)
  • Syphilis
  • Disseminated TB
  • In the more immunosuppressed host:
    
    • Mycobacterium Avium Complex
    • Bartonella Henselae
    • Disseminated fungal infection (i.e. histoplasmosis)
• Non-infectious
  
  • Lymphoma
    
  • Multicentric Castleman's Disease
  • Sarcoidosis
    

I have previously blogged about HIV here, here (with cryptococcal meningitis), and here (with PCP pneumonia).

I have blogged about lymphoma including staging here.

A review of the pathology of HIV associate lymphomas is here. An article reviewing the treatment of HIV associated lymphoma is here.

Day #299 - Enterococcal Prosthetic Valve Endocarditis

Great case. I have previously blogged about the diagnosis of endocarditis here and here.

Patient with multiple prosthetic valves develops sepsis in the context of an enterococcal bacteremia. Highly suspicious though non diagnostic echo for PVIE. Treated with VANCOMYCIN ("penicillin allergy" is a pet peeve of mine) and GENTAMICIN (for synergy). The evidence for synergy is not totally supported by clinical experience. Nephrotoxiciy is common but similarly has not been shown to impact mortality. The combination of VANCOMYCIN with an aminoglycoide increases the risk of nephrotoxicity.

We also reviewed aminoglycoside ototoxicity -- presenting either as sensory-neuro hearing loss or vestibulary dysfunction.

This patient developed renal failure presumably related to ATN from the VANCO+GENT; however, one can get a glomerulonephritis in endocarditis.

There is evidence that AMPICILLIN plus CEFTRIAXONE (which usually has no enterococcal coverage) can be used effectively in the treatment of enterococcal endocarditis.

Day #295 - Tuberculosis and Immune Reconstitiution

We discussed a case of pulmonary and extrapulmonary tuberculosis which presented on TNF-alpha antagonist therapy.

Addendum: TB Immune Reconstitution Reviewed Recently here.

We also discussed paradoxical worsening of TB post-discontinuation of immunosuppression. The case report I was talking about is available here.