NTC 11/21/22 — Deep Neck Space Infections

At noon teaching conference today, UCSD Infectious Disease specialist Dr. Cowell led us through the case of a 37-year-old man who presented with one week of left neck pain and swelling (three weeks after an episode of tonsillitis) and was found to have left parapharyngeal space infection 2/2 Fusobacterium necrophorum with bacteremia. CT and US of neck/neck vasculature showed no evidence of septic thrombophlebitis of the left internal jugular vein, the feared complication of Fusobacterium parapharyngeal space infection. He was treated with IV Zosyn with significant improvement in his symptoms and was discharged on Augmentin to complete a three-week course of antibiotics.

We discussed how deep neck space infections can be divided based on the anatomic spaces — defined by cervical fascia — that they occupy. The major spaces are the peritonsillar space, submandibular space, pretracheal space, parapharyngeal space, retropharyngeal and danger spaces, and prevertebral space. Deep neck space infections can lead to life-threatening complications involving structures neighboring these spaces, including airway obstruction (peritonsillar, submandibular [Ludwig angina], pretracheal), carotid artery mycotic aneurysm/erosion (parapharyngeal), septic thrombophlebitis of the internal jugular vein c/b septic emboli (parapharyngeal [Lemierre syndrome]), mediastinitis (danger space), and cord compression (prevertebral).

CPRS Outage

For unplanned CPRS outages, there is a read only version of CPRS. You can find this under SDC Shortcuts call Downtime VistA Read Only. This has the most recent labs and imaging reports and all notes. Orders can be handwritten, notes can be written in Microsoft Word printed for the night team and put into CPRS later. If you admit patients during an outage, the night time team does not put in orders overnight. The handwritten orders stand and are entered into CPRS in the morning by the admitting team. This is to reduce the possibility of mistakes. There is no alternative to SOCS but the ED usually has a list of pagers for the most important consultants: Surgery, Cards, etc.

Remember! You can always contact the Chief on Call for help during these times if you aren’t sure what to do!

FRIDAY SCHOOL 11.18.22

It’s our favorite time of the week again! FRIDAY SCHOOL! Today our interns learned about GI Bleeds from Dr. Kyle Geary.

The seniors started out with our Excellence in Quality Improvement and Patient Safety conference. Next we kicked off the Rheumatology block with a bang with lessons in Crystal Arthropathy and Systemic Vasculitis.

Both seniors and interns re-convened for an AHEAD (Advancing Health Equity and Diversity) session which was a thought provoking discussion about Reproductive Health in collaboration with our OB/Gyn colleagues [see below for article].

Noon Teaching Conference 11.15.22: TB or not TB, that is the diagnosis

Picture above is from https://www.nejm.org/doi/pdf/10.1056/NEJMicm2001934. A representative picture similar to this patient’s presentation.

Today, we talked about a fascinating patient who has suspected military tuberculosis AND military histoplasmosis. We were joined by Dr. Morgan Birabaharan (ID fellow and former UCSD PSTP resident). We discussed that about 15-20% of patients with military findings on imaging have both a fungal infection and tuberculosis. While the medications to treat these infections are complicated with serious side effects, the risk of not treating is very high.

Key Takeaways:

  1. Military TB needs to be treated or is uniformly fatal
  2. Common microbiological tests in patients with advance HIV can be unreliable and the index of suspicion needs to remain high
  3. Our Owen service is amazing!

11/15 VA Recruitment NTC

Today for our recruitment noon teaching conference, we were joined by our amazing resident Dr. Edward Wang who shared a complex case of a middle aged woman presenting with recurrent strokes and pancytopenia. During a tumultuous hospital course complicated by GI bleed and STEMI, she underwent a bone marrow biopsy for her pancytopenia and was ultimately found to have acute promyelocytic leukemia likely driving her profound coagulopathy. Our fantastic expert discussant and UCSD alumna Dr. Tiffany Tanaka from Heme/Onc shared several pearls on interpreting peripheral smears as well as diagnosing and treating APL. Thank you so much to Dr. Wang, Dr. Tanaka and our amazing residents for helping us learn from an incredible case!

NTC 11/14/22 — CML

At noon teaching conference today, UCSD Hematologist/Oncologist Dr. Tanaka led us through the case of a 79-year-old man with a history of T2DM, HTN, CKD3, GERD, and gout, who presented to continuity clinic to establish care and was found on routine labs to have leukocytosis to 36.3 with neutrophilia, immature granulocytes, eosinophilia, basophilia, and monocytosis. Peripheral smear showed no blasts and RT-PCR detected BCR::ABL1 fusion gene products. The patient was determined to have chronic myeloid leukemia and was started on the tyrosine kinase inhibitor imatinib.

We discussed the approach to leukocytosis and how the differential diagnosis differs based on the type of leukocyte that is elevated (lymphocytosis, neutrophilia, eosinophilia, basophilia, and monocytosis). We then discussed the natural history of CML (chronic phase > accelerated phase/blast crisis) and the use of BCR::ABL1 tyrosine kinase inhibitors as very effective first-line therapy (imatinib, dasatinib, nilotinib, bosutinib).

HIV One Year Fellowship Opportunity!

Exciting news for those post-grad and 3rd year residents interested in HIV Medicine!

HIVMA and the IDSA Foundation are accepting applications for the 2023-2024 HIV Clinical Fellowship training year.

Who: Graduating/graduated residents not trained in infectious diseases

What: One year clinic training in HIV fellowship program under the mentorship of an HIVMA member at clinical sites serving medically underserved populations (Dr. Darcy Wooten at Owen Clinic).

When: The application period will close December 12

Next steps: Contact Dr. Darcy Wooten for further details and discussion! dawooten@health.ucsd.edu

NTC 11/10/22 — Hemolytic Uremic Syndrome

At noon teaching conference today, PGY-3 Ben Yang and Nephrologist Bethany Karl guided us through the case of a young woman who presented with bloody diarrhea and was found to have pancolitis, severe AKI, microangiopathic hemolytic anemia, and thrombocytopenia. Her GI pathogen panel later returned positive for E coli O157. She was diagnosed with likely typical HUS, but she was treated with therapeutic plasma exchange while her ADAMTS13 activity level was pending (later resulted as only mildly low, inconsistent with TTP). She was also started on eculizumab, a monoclonal antibody that interferes with complement activation and is indicated for treatment of atypical HUS.

We discussed the difference between TTP, HUS (typical and atypical), and DIC. We also discussed treating TTP with TPE and glucocorticoids (and possibly rituximab and caplacizumab) and treating typical HUS with supportive care.

Noon Teaching Conference 11.08.22: Blistering Distal Dactylitis

Today at Hillcrest, during our Owen clinic conference we were joined by Dr. Daniel Lee one of our HIV specialists. We discussed an interesting case presentation of a patient with HIV who is immunocompetent who presented with blisters and bullae on his hands. Dermatology thinks this is likely blistering distal dactylitis but porphyria cutanea tarda studies are still pending. Thanks to Jessica Xiao (PGY2) for an outstanding case presentation!