Hillcrest MTC: Something Fishy in the Blood…

Today during HC MTC, one of our R2’s, Jared Rosen, presented a patient who was admitted four (!) times for symptomatic anemia in the last 3 months. On previous hospitalizations, she presented with hematemesis and was found to have a peptic ulcer that was thought to be the source of her hematemesis. On the current admission, the patient had no reported hematemesis or other sources of bleeding or bruising, but presented to the ED with a hemoglobin on 4.2. She was found to have low-grade hemolysis, a hypoproliferative reticulocyte index, and several RBC abnormalities on her peripheral smear (1-2 spherocytes/HPF, rare schistocytes, and dacrocytes). DAT was positive (anti-C3+ and anti-IgG negative) suggestive of cold agglutinin disease that is suspected secondary to potential malignancy or myelodysplastic disorder. The patient underwent a bone marrow biopsy to look for potential malignancy and the results are pending. Thanks to Jared for presenting such an interesting case!

Take-Home Points:

1.) The differential for anemia should be separated by hyperproliferative (compensatory) and hypoproliferative (inadequate production) causes. The reticulocyte index is useful for differentiating between these two causes but should only be calculated off a pre-transfusion CBC.

2.) Peripheral smears are useful for further evaluating anemia as they provide clues to potential causes. Schistocytes indicate some form of microangiopathic hemolytic anemia spherocytes can indicate either hereditary disease or agglutinin-mediated disease. Dacrocytes can suggest a bone marrow infiltrative process.

3.) Cold Agglutinin disease is associated classically with mycoplasma, EBV infections, monoclonal IgM gammopathy, and lymphomas or other lymphoproliferative disorders.

Grand Rounds – 5/12 – Dr. Heerspink

This week we were fortunate to host Dr. Heerspink, a prominent researcher in the field of nephrology who shared his research on SGLT2-I and rate of CKD progression.

Take home points:

-Current treatment of ACEi and ARB are insufficient to slow CKD progression
-The SGLT@-I dapagaflozin reduces the risk of kidney failure and heart failure hospitalization in patients with and without diabetes at various stages of CKD
– The protective effects are unrelated to improvements in glycemic control and are in part attributed to reduction in glomerular hyper-filtration
-Other effective therapies are ERA atrasentan and MRA finerenone but are associated with side effects
-Finding the optimal combination for individual patients will be the future to optimize kidney protection

University of Washington Division of Metabolism, Endocrinology and Nutrition Fellowship Program – virtual information session on May 25, 4-5pm PST 

The University of Washington Division of Metabolism, Endocrinology and Nutrition Fellowship Program is hosting a virtual information session on May 25, 4-5pm PST for applicants interested in pursuing an Endocrinology Fellowship.  Registration is required, and you can register here.  Dr. Tracy Tylee, Program Director, and Dr. Josh Thaler, Associate Program Director, will be hosting a virtual recruitment session to go over our curriculum structure, our hospital systems, and what living and working in Seattle and the Pacific Northwest is like.   

Alumni in both the clinical scholar and research tracks have moved onto successful careers as clinical endocrinologists, researchers, and academic faculty in the Pacific Northwest and across the nation. Division faculty are also very active in teaching medical students and residents.

More information about our curriculum and track options can be found here.

We encourage applicants and families to join us!  If you have any additional questions, please reach out to Alex Stoller, Fellowship Administrator

Tuesday Owen Report at Hillcrest

Today at Owen Report, one of our stellar R2’s, Anna Ter-Zakarian, presented a case of a patient she recently cared for in the ICU. He had advanced HIV with a CD 4 count of 3 (!) and presented with acute shortness of breath, tachypnea and hypoxemia requiring 60 L of 100% oxygen. Chest radiograph revealed diffuse opacifications and blood gas had markedly elevated A-a gradient. A broad infectious work-up was sent and the patient ended up having both Pneumocystis Jiroveci and Cryptococcal pneumonias. 

Due to the patient’s acute symptoms onset (rather than subacute and gradual as would be expected with these organisms), and recent re-initiation of ART, there was high concern for Immune Reconstitution Inflammatory Syndrome (IRIS). We discussed how IRIS “unmasks” occult and asymptomatic opportunistic infections and why it is important to rule out cryptococcal meningitis. We also discussed that some patients may present with “paradoxical” worsening of inflammatory symptoms even as their OIs are being treated. We also learned that IRIS can unmask undiagnosed autoimmune conditions. Risk factors for IRIS include low CD4 count and high viral loads. The treatment includes steroids as well as ongoing treatment of any underlying OIs and (usually) continuation of ART. 

Thank you to Dr. Laura Bamford for being our expert discussant and sharing many valuable pearls with our audience!  

Lung holes aren’t empty, they’re filled with narrowed differentials!

Today at the VA MTC we discussed a current patient at UCSD admitted for reactivation TB!! The patient moved to San Diego from Kazakhstan in 2018, and developed a chronic cough. CXR in clinic identified a cavitary lesion, and due to concern for active TB the patient was sent to the ER for further testing. She had multiple different studies sent for different infectious and vasculitic causes of cavitary lesions, but ultimately her AFB sputums were positive! This gave us a great opportunity to review the common hole-y lesions of the lung, their differences, and their differentials!! See below!!

These are all types of ‘holey’ lung disease that YOU as internists can help distinguish! Sometimes there can be some challenging areas of a patients lung to suss out, but most of the time we can distinguish these lesions ourselves. And what’s great about that is that each has a unique differential, which can help us better hone in on the diagnosis!

5/7 ID/Global Health Friday School

Today was week #2 of our Friday School block! We had a lecture by Dr. Elliott Welford on Coccidioides where we discussed common symptoms, diagnosis and treatment of this endemic fungi. A big pearl from this session was that a patient presenting with pulmonary cocci who is relatively stable, otherwise healthy and no e/o dissemination can be treated symptomatically and does not require antifungals! Afterwards, Dr. Titchen gave a presentation on human trafficking, an issues that unfortunately occurs throughout the United States. We learned about the different resources available for our patients as well as signs to look out for. We finished off with a great session on by Dr. Stephen Rawlings who presented a cornucopia of various micro cases. There were many pearls, including what GIPP can and cannot detect, what is in the biofire meningitis assay, c diff testing, cavitary pulm lesions, COVID, legionella and more!

Congratulations Stacy Han for receiving the Humanism in Medicine Award!

We want to congratulate Stacy Han for winning the UC San Diego SOM Humanism in Medicine Resident Award in Internal Medicine. She was recognized by third year medical students as someone who exemplifies compassion, dedication and a humanistic approach to patient care in addition to being a role model for others. She has been invited to join the UC San Diego SOM’s Chapter of the Gold Humanism Honor Society and will be recognized at the Student Clinicians Ceremony. Three cheers for Stacy! We are proud of you!

THORacentesis, the Norse God of Pleural Effusions

Today at Hillcrest we had PGY4 and future Bay-area hospitalist Dr. Conor Holton-Burke present a case of a thoracentesis gone wrong. This patient had a chronic unilateral effusion, and received a diagnostic + therapeutic thoracentesis in order to address it, but suffered sudden-onset chest pain right after the procedure!! WHAT DO YOU DO?! Let’s review below!

  • Indications for Thoracentesis
    • Diagnostic
      • Identify cause (for cases that are NOT obviously heart failure or small parapneumonic effusion). The features that support thoracentesis are:
        • Lack of resolution after sufficient diuresis
        • Disparaging sizes of bilateral effusions
        • ECHO not c/w heart failure
        • Concern for cancer
        • Concern for empyema or large parapneumonic effusion
    • Therapeutic
      • Symptomatic relief (can even put in long-term for palliative measures)
        • Dyspnea
        • Chest discomfort
      • Preventing pleural thickening in certain conditions
        • Hemothorax (should be considering chest tube instead)
        • Reactivation TB
      • Management of complicated pleural effusion
        • Parapneumonic effusion
        • Empyema (should be considering chest tube instead)
  • The actual procedure!
  • Complications
    • Pneumothorax: 3% of U/S thoras, >12% of thoras w/o U/S
    • Pain: local needle pain, trapped lung (negative pressure pain)
    • Bleeding: outside, or hemothorax
    • Local infection (or rarely even empyema from seeding)
    • Damage to surrounding structures: usually Liver/Spleen from going too low

Asian Pacific American Heritage Month

May is Asian Pacific American Heritage Month! As we celebrate the contributions Asian Americans have given to US society, we are reminded of the recent string of violence against people of Asian or Pacific Islander heritage. As a residency program, we are committed to expanding our DEI initiatives in order to ensure a welcoming environment for our residents, patients and staff. Please check the statement below by the Alliance for Academic Internal Medicine (AAIM) to learn more about some of the DEI initiatives that are occurring across the country.