Morning Teaching Conference: Acute Invasive Fungal Sinusitis

Teaching Points

Most common fungi that cause invasive fungal sinusitis are Fusarium, Aspergillus and Mucorales.

Host risk factors include diabetes mellitus, ketoacidosis, HIV, hematologic malignancies, BMT, neutropenia, steroids

Galactomannan and beta-D-glucan are cell wall components of multiple fungi. Galactomannan is more specific to Aspergillus however can be positive in other fungi such as Fusarium. Beta-D-glucan is more sensitive for Aspergillus however less specific (can also be a good screening test for PJP)! Both galactomannan and beta-D-glucan are negative with Mucorales.

Given low sensitivity of galactomannan, beta-D-glucan, and fungal culture in detecting invasive fungal sinusitis, specifically due to Mucorales, tissue/histopathology is required for diagnosis! Call ENT!

Morning Report 10/20

Today with our amazing APD, Dr. Sladek, we tackled an outpatient case involving an 87 year old patient presenting to clinic to discuss changes in her memory. Our patient’s daughter noted difficulty cooking and cleaning, inability to drive due to getting lost and difficulty managing her finances along with worsening gait imbalance and urinary incontinence.We first highlighted that our approach to these patient which includes getting a detailed history of the symptoms, including collateral from friends or family. Important questions to ask include level of impairment, time course, any relation to delirium or depression, and medications including over the counter supplements.

Next we reviewed the criteria for diagnosis of Major Neurocognitive Disorder and reviewed the reversible causes of MND (see slides). Finally after reviewing our patient’s physical exam and obtaining imaging we were able to diagnose her with Normal Pressure Hydrocephalus, a rare cause of reversible dementia.

NPH Pearls:
– patient present with magnetic gait, urinary incontinence and dementia
– Can be diagnosed with history and imaging, and confirmed with large volume lumbar puncture.
– Patient’s with disease amenable to surgery can be treated with VP shunting

Friday School 10/16: “Resident as Clinician Educator” and SLE

Our first block was a “Resident as Clinician Educator” session! We got to both learn and practice how to incorporate teaching on rounds and using “hold-overs” as another great learning opportunity for interns and medical students!

Our second session was all about lupus! We first broke up into small groups to make creative ways to test each other on the clinical manifestations, work up, and treatment of SLE! We then reviewed SLE with Dr Corr! Big take away points:

Systemic Lupus Erythematous

Clinical Manifestations: Serositis (pericardial and pleural surfaces), lupus nephritis, arthritis, Raynauds, hematologic (low lymphocytes, anemia), neurologic (very large spectrum of disease from depression to seizures), rash (malar rash, discoid, annular rash which all appear in more photosensitive areas)

Work up? It’s not just an antibody soup! ANA is most sensitive (however not specific!), Anti-SM (more specific), anti-SSA/SSB (good for screening for risk of neonatal lupus), anti-dsDNA (can be used to monitor disease activity), C3/C4 (if low, think possible lupus nephritis)

Treatment: Hydroxychloroquine (best uses are arthritis, skin disease, serositis, reduction in CVD risk), MMF/Cyclophosphamide (for lupus nephritis), Topical Tacro/Steroids (cutaneous manifestations), Biologics (rituxan, obinutuzumab, belimumab)

How to counsel your SLE patients: Increased CVD risk (smoking cessation, diet/exercise, HTN, daily aspirin), minimize UV exposure, increased osteoporosis risk (minimize steroid use, weight bearing exercise, Ca and Vitamin D intake), Increased cancer risk (lung cancer, cervical cancer, NHL and Hodgkin’s lymphoma), and discuss family planning!

To access the presentations and resources for each Friday School session, check out our Friday School section on the blog and click Rheumatology and Allergy/Immunology

Continuing Medical Education

The Scope is a once a week email that will send consolidated blurbs about new, exciting journal articles so that you can stay up to date on the latest medical news! Furthermore, each summary comes with a link to the full article if you want to review it in full (see example below)! This is a fun, easy way to keep up with the latest medical literature! Check out The Scope (https://www.medicinescope.com) to subscribe! Thank you to Dominic Picetti (PGY3) for alerting us to this resource!

Wellness at Jacobs Onc Conference

Today, our Jacobs residents got a chance to discuss their tough cancer cases in a safe space and amongst peers. This was done through protected time, and accomplished not only through sharing stories, but through discussion of strategies for coping, wellness and rejuvenation. The session concluded with discussion regarding identifying and intervening on those around one’s self. Other team-members, such as co-residents, interns, or medical students, may try to shoulder too much emotional weight while caring for patients, and being a part of a team together means looking out, and advocating for one another.

See? You can literally lift each other up.

Patient care is extremely rewarding. However, it can also take tremendous tolls on caregivers and care teams. Residents are no exception to this rule. In fact, with the time commitment and stress experienced during residency, it often requires intentional effort to identify and engage in healthy coping strategies.

Expand your capacity on Capacity Assessments

Our amazing residents Ali Crisp, Ann Xing and Aram Namavar created an awesome document to help with capacity assessments on the floor! It includes a great framework and some good pointers to assist you in making capacity assessments for you patients. Cheers to Ali, Ann and Aram for making such a great tool!

You can find the document here or in the protected: ward, unit and cross cover document page

Morning Teaching Conference 10/15/20 – CMV Colitis!

Today we presented a very interesting patient with a case of CMV Colitis! The patient originally presented with a new diagnosis of IBD that initially improved with prednisone therapy, but then presented with worsening abdominal pain and diarrhea. The patient was found to have both CMV colitis as well as active Crohn’s disease. We discussed a differential for infectious colitis, and our expert discussant Dr. Cathy Logan shared with us some important pearls for infectious colitis in an immunocompromised patient.

Take Home Points:

  1. Colonoscopy and biopsy are critical for differentiating an IBD flare from infectious colitis
  2. Differential for infectious colitis includes:
    1. Bacterial: Campylobacter, Yersinia, ETEC, EIEC, EHEC, Shigella, Salmonella, Vibrio, listeria, Clostridium
    2. Viral: CMV, HSV, Rotavirus, enterovirus, adenovirus
    3. Parasitic:  Amebiasis, giardia, schistosomiasis
  3. The gold-standard for diagnosing CMV Colitis is tissue biopsy. Negative serum PCR does NOT rule out CMV colitis
  4. Treatment options for CMV colitis include ganciclovir, valganciclovir, foscarnet, and cidofovir

10/14 Grand rounds – Thrombotic Microangiopathies: New Concepts and Treatments

Today we had the pleasure of hosting Dr. Weitz for Medicine Grand Rounds! Dr. Ilene C. Weitz is an Associate Professor of Clinical Medicine at the Keck School of Medicine at the University of Southern California (USC). Her practice sites include, LAC+USC Medical Center, Keck Hospital of USC and USC Norris Cancer Hospital. Dr. Weitz is board certified in Internal Medicine and Hematology.Dr. Weitz earned her medical degree at Medical College of Pennsylvania in Philadelphia, followed by an internship and residency in internal medicine at Cedars-Sinai Medical Center. She conducted a fellowship in hematology/oncology at Scripps Clinic and Research Foundation in La Jolla, California. Dr. Weitz’ research and clinical interests include hematologic disorders such as anemias, thrombocytopenia and white blood cell disorders, paroxysmal nocturnal hemoglobinuria (PNH), immune mediated anemias and thrombocytopenia, thrombosis and hemostasis.

Her talk today was on Advances in the Understanding of Thrombotic Microangiopathies TTP and aHUS. TTP is classically describes with the pentad of symptoms (thrombocytopenia, MAHA, fever, neurologic manifestations and renal dysfunction). The classic cause of TTP is due to an acquired deficiency in ADAMTS13, but rarely can be caused by a congenital genetic defect. This leads to ultra large molecules of VWB that cause platelet clumping in the vessels and ultimately vessel destruction. Given that this disease is driven by an acquired deficiency in ADAMTS13, treatment options focus on replacing ADAMTS13 with plasma exchange or infusion vs. suppressing the inhibitor with steroids or agents like rituxumab. Lastly we talked about how there is ongoing research into the long term sequelae that patients with TTP experience including: relapse, cardiovascular disease, HtN, obesity, lasting neurologic sequelae, DM and renal failure.

Noon Conference 10/14 – Aspirin Exacerbated Respiratory Disease

Today at noon conference Dr. Galant-Swafford and Dr. Doherty gave a fascinating lecture on Aspirin Exacerbated Respiratory Disease (AERD). Dr. Galanat-Swafford started with an excellent case of a patient presenting with nasal congestion and chronic loss of his sense of smell. This patient was found to be sensitive to Aspirin through testing. Dr. Doherty reviewed the phenotypes of AERD as well as the underlying pathophysiology including possible treatment options. The patient was ultimately treated with dupilumab and had complete resolution of his symptoms!

Take away

  • AERD – presents with asthma, nasal polyps, and bronchoconstriction with ASA or other Cox-1 inhibitors.
  • Due to underlying dysregulation of arachidonic acid pathway, causing a baseline overproduction of leukotrienes
  • It can be diagnosed with an aspiring challenge and can be treated by ASA desensitization, dupilumab or leukotriene inhibitors.
  • In patients you suspect of having this refer to Allergy for further evaluation!