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.

Day #126 - Hepatitis B

Today we discussed a patient with acute hepatitis on the backgroud of hepatitis B chronic infection. I have previously discussed acute hepatitis, cirrhosis and complications thereof.

I wanted to talk about hepatitis B -- Firstly, this is a great review article and so is this.

Secondly - Serologies:

• Early in infection you have the production of Hepatitis B Surface Antigen and Hepatitis B Envelope Antigen which represents active infection
• The you develop hepatitis B core IgM then core IgG. These antibodies are not protective
• If you are going to clear your infection you will next develop anti-hepatitis B-EAg antibodies, clear your E antigen and then start to clear your S-Antigen
• You then make hepatitis B surface antibodies
• There can be a window period in between clearing the S-Ag and developing the anti-HepB surface antibody where the only way you will know if they are infected is by the core antibody.

An immunized person will only have hepatitis B surface antibody

A natural, but cleared infection will have positive HepB surface antibody and core antibody and no surface antigen

A patient with chronic active hepatitis will have core antibody and in most cases hepatitis B surface antigen. They may also have E antigen (or E antibody). They will not have surface antibody.

For chronic carriers treatment depends on a number of factors -- this table provides an excellent summary:

---

Note that I link to a lot of NEJM articles. This is my preferred journal. Those of you with a U of T library account have NEJM access via e-journal search in the gerstein library website. We pay for an institutional license @ U of T which you can access at home and there is a licence here at the hospital.

Those of you who would like their own subscription (b/c above don't work) can obtain one here ($~60/year for electronic only ~ $150 for print copy too)

Day #124 - Pretibial Septic Bursitis

Today's case was of a painter, who did a lot of work on his hands and knees, presenting with acute onset knee pain. We discussed the differential diagnosis in detail and then focused on septic arthritis. I have previously blogged about this here and had linked to an excellent article that I recommend you reading.

In this case, the diagnosis was pretibial septic bursitis, which can mimic septic arthritis and is commonly seen in people who do labor on their hands and knees and is associated with minor traumas. The most common infectious aetiology is stapylococcus aureus.

Day #119 - Adult Onset Still's Disease

This was a great case which the discussant enjoyed taking us through. I have previously blogged about fever of unknown origin here, here and here.

There was a previous special guest blog about FUO here.

Here are articles suggested by the discussant on rheumatologic causes of FUO, Adult Onset Still's Disease, and the use of IL-1 antagonists in the treatment of Still's.

Here is another review on Stills.