This morning we were lucky to be joined by Dr. Darcy Wooten, an amazing HIV Medicine attending and APD of the Infectious Disease Fellowship, to discuss one of her Owen clinic patients.
The 30-year old man with newly diagnosed HIV presented to our hospital with cough, fevers, chills, night sweats, decreased appetite, and recent weight loss. On admission, the patient had a CD4 count of 102 cell/uL and viral load of 185,000 copies/mL. The CXR revealed a diffuse micronodular/miliary pattern and CT showed upper lobe predominant diffuse ground glass opacities. Initially concerning for TB, the patient’s work-up was significant for elevated serum Coccidiodes IgG antibodies, positive cocci complement fixation with a 1:512 titer, and negative bone scan and spine computerized tomography. The patient was diagnosed with severe pulmonary coccidioidomycosis with presumed dissemination (based on the high titer).
The patient was treated with amphotericin B for severe cocci and discharged on fluconazole therapy (along with antiretroviral therapy and Bactrim prophylaxis). He could not tolerate the fluconazole and was switched to Posaconazole. The patient subsequently developed severe hypertension refractive to amlodipine, lisinopril, and hydrochlorothiazide. Work up demonstrated low levels of potassium, renin, and aldosterone. The patient was diagnosed with pseudohyperaldosteronism, taken off Posaconazole, and placed on itraconazole and spironolactone, leading to a resolution side effects. The mechanism behind pseudohyperaldosteronism is similar to that of licorice root extract, where steroid synthesis products directly activate mineralocorticoid receptors. Treatment is focused on cessation of Posaconazole and antagonism of the mineralocorticoid receptor with spironolactone.
This morning one of our stellar resident, Dr. Mandy Mohindra, presented a patient who developed a fever six days into a hospitalization for volume overload. The patient reported a history of worsening chills with rigors, loss of appetite, nausea and vomiting, and fatigue. He had an infiltrated IV with right upper extremity swelling on exam. The patient’s history was significant for liver transplantation three years before (on tacrolimus), diabetes, and severe aortic stenosis. We discussed the decision to start empiric antibiotics, and the workup eventually revealed MRSA bacteremia. The most likely source was the infiltrated peripheral IV.
We were lucky to have our Infectious Disease expert extraordinaire, Dr. Annie Cowell, to lead us through the management of Staph Aureus bacteremia as we discussed the need to evaluate for potential sites of metastatic MRSA infection. A wrinkle in our patient’s case was that his blood cultures were persistently positive for MRSA. This prompted a change of antibiotics from vancomycin to ceftaroline and daptomycin and a search for endocarditis. A transthoracic echocardiogram did not reveal valvular vegetations, but a subsequent ECG revealed a new 1st degree heart block. The patient underwent a transesophageal echocardiogram which ultimately demonstrated a paravalvular abscess for which cardiothoracic surgery was consulted. Thank you to all of our resident teams for participating in the discussion. And thank you to Dr. Cowell for adding context to our patient’s clinical course!
Mandy Mohindra and Ian Drobish, our inaugural Global Health Pathway residents, participated in an interdepartmental simulation with fellow Emergency, Surgery, and OB/GYN residents. The simulation centered on a patient presenting with profound dehydration from a diarrheal illness. The resident teams had to manage the resuscitation while figuring out the underlying etiology (cholera!) and overcoming a twist – the patient was also pregnant.
The teams then participated in a socially distanced debrief and dinner while discussing the realities of providing medical care in under-resourced settings. The session ended with skills stations which taught trainees how to establish intraosseous access (without an EZ-IO device!), calculate fluid drip rates for IV medications, and mix-up homemade oral rehydration solution. Thank you, Ian and Mandy, for representing our program and bringing your A game!
I just want to remind and plead with you to please keep our UCSD family safe by socially distancing, masking and washing your hands, at work and away from work. See the news story below about 18 anesthesia trainees in a program in Florida infected with COVID after a party. Please protect yourself, your loved ones (including our UCSD IM family) and our patients. We are role models and we are essential
This morning we discussed a case of 42-year-old man who presented to UCSD Hillcrest with a history of subacute cough and shortness of breath. Review of systems was additionally notable for subacute fevers and chills, night sweats, weight loss, and progressive generalized weakness. His sexual history was suspicious for potential undiagnosed HIV infection, and we created a differential of possible pulmonary disease in HIV+ patients by CD4 count. His CXR and elevated LDH and beta-D glucan (sensitive although not specific) were suspicious for PJP. The diagnosis was ultimately diagnosed by sputum silver stain, and we discussed the frequent need for bronchoscopy with BAL to obtain adequate sample. After initiation of treatment with TMP-SMX, the patient’s respiratory condition worsened, and we discussed the role of systemic steroids in PJP treatment. Thank you to Dr. Darcy Wooten from Infectious Disease, who guided us through the differential diagnosis and provided many relevant clinical pearls.
Please check your UCSD badges! If you have not been fitting for the 8210 (you should have a sticker with these numbers on it) or the Gerson, please go get fitted through Infection Control at UCSD. They are at both sites today, 5/28 and tomorrow 5/29, at Hillcrest in the 8th floor tower link conference room 8-309 and in La Jolla in JMC 6-708 conference room from 6am-10pm.
Today our amazing PGY-2, Dr. Alexis Quade, led us through an interesting case of an elderly woman who initially came in with some knee pain but was found to have an AKI and sepsis in the ED. We found out that she had untreated psoriasis, a bioprosthetic valve and a recent Staph Aureus UTI. Her exam was notable for extensive, near full body, erythematous desquamating lesions sparing mucosal membranes, with a yellowish crust but otherwise hemodynamically stable that was concerning for erythroderma. Our expert discussant from dermatology, Dr. Nell Haddock, helped us learn about the pathophysiology of erythroderma and the most common disease processes that will cause this condition. Dr. Quade reminded us that erythroderma, given the large degree of vasodilation and shunting of blood flow, can be a cause of high-output heart failure. Ultimately, the patient was diagnosed with impetiginized psoriasis and staph bacteremia and greatly improved with IV antibiotics and topical steroids.
1) Remember to look for possible bacteremia and occult infection in patients with Staph bacteruria
2) Erythroderma is a dermatologic emergent condition that is defined by an exfoliative dermatitis that covers over 90% of the body and is caused by a number of disease states.
3) Treatment includes aggressive wound care and hemodynamic monitoring given large degree of insensible losses and control of underlying disease process. Remember, do not use oral steroids for psoriasis flares, start with topical steroids +/- immunologics!
Thank you again, Dr. Quade, for the great case and to Dr. Haddock, for your amazing teaching!