This Thursday, we restarted our join teaching conferences with our partners in Maputo, Mozambique! We discussed a case of an 83-year-old man who presented with several months of progressive shortness of breath, dry cough, and weight loss. On exam, he had absence of breath sounds over the right hemithorax with dullness to percussion and absent tactile fremitus. His chest radiograph demonstrated unilateral white out, and we considered two possibilities for this finding: a large pleural effusion or a mainstem bronchial obstruction causing lung collapse.
Our expert discussant, the legendary VA pulmonologist Dr. Judd Landsberg, guided us through the CXR interpretation and why it was consistent with an effusion: large spacing between ribs and tracheal deviation away from the affected hemithorax.
A thoracentesis was performed and was consistent with an exudate by Light’s criteria. We formed a differential for exudative effusion and discussed why two possibilities were most likely for this particular patient: malignancy and Tuberculosis. Unfortunately, the patient’s thoracentesis was followed by the discovery of a pneumothorax. We considered the mechanism and management of this complication and how to proceed in case where the pneumothorax is increasing: placement of a chest tube.
Thank you to Dr. Landsberg for all of his clinical pearls and the Maputo residents for their participation!
Today our amazing Med/Peds PGY3, Jack Strutner, led us through a case he saw in Mozambique at his time at Maputo General Hospital. His patient was a young man with HIV who came in with subacute diarrhea with profuse bloody bowel movements and a fever. He was found to be severely volume depleted and with an AKI on exam. We worked through our diagnostic schema and work-up of diarrhea in an HIV patient, focusing on infectious etiologies. Our expert discussant from Infectious Diseases, Dr. Stephen Rawlings, helped further flesh out our differential for these patients and discussed ARV side effects. We then discussed the differences in work-up approaches for patients in resource poor settings vs here in the US, with the main difference being more focus on stabilization and resuscitation with empiric antibiotics and less so on diagnostic tests. The patient unfortunately passed which we discovered is sadly a common scenario on a global scale, highlighting the importance of ongoing global efforts to improve water supply and sanitation in disease prevention.
Take away points:
1) Remember to take a thorough history regarding diarrhea onset, characteristics (volume, content, frequency) and associated symptoms
2) ARVs, particularly protease inhibitors, integrase inhibitors and Zidovudine (causing acute pancreatitis) may be the cause of diarrhea in some HIV patients
3) Diarrheal illness is still a leading cause of death worldwide, particularly in resource poor nations
Thank you again to Dr. Strutner for a thought provoking case, and to Dr. Rawlings for always providing great teaching! We hope to hear from our colleagues in Maputo sometime again soon!
Go RS, Winters JL, Kay NE. How I treat autoimmune hemolytic anemia. Blood. 2017 Jun 1;129(22):2971-2979.
Today Dr. Susan Seav presented a case of bloody diarrhea in a young male. The combination of elevated bilirubin, anemia, and reticulocytes on his blood smear raised concern for underlying autoimmune hemolytic anemia, and the patient was diagnosed with WAIHA secondary to lupus. Up to 10% of patients with WAIHA are DAT/Coombs negative, as with this patient. For more on WAIHA classification and serology, see the figure above from the referenced 2017 Blood review article on the subject. Many thanks to Dr. Fotis Asimakopoulos for serving as our expert discussant!
Today at the VA for our Maputo Case Conference, Dr. Neal Jones presented a fascinating case of an elderly gentleman presenting with subacute URI symptoms and progressive gross hematuria. He was found to have an AKI, pulmonary infiltrates on CXR, and multiple large renal cysts on CT. The patient was also noted to have significantly elevated CRP and ESR. He was initially treated for suspected pneumonia and infected renal cyst, but after several days without improvement and a steadily increasing creatinine, the work-up for his hematuria revealed PR3/C-ANCA positivity. A subsequent renal biopsy demonstrated diffuse crescentic glomerulonephritis, consistent with rapidly progressive GN 2/2 GPA! Dr. Tomasz Beben, nephrologist extraordinaire, then walked us through the nuances of GPA diagnosis and management. Our patient ultimately demonstrated signs of renal recovery after receiving high-dose methylprednisolone, rituximab, and several sounds of plasmapheresis. Thank you Drs. Jones and Beben for a great case presentation and excellent discussion!
Take Home Points:
GPA is uncommon, but with a constellation of sinopulmonary and renal findings, it should always be on the differential.
In the past, the diagnosis of GPA was made exclusively by renal biopsy, but many nephrologists are moving towards treatment after confirmed PR3/C-ANCA positivity.
Patients with GPA require pulse dose and then prolonged steroid use. For severe cases, there is also a movement to use rituximab rather than cyclophosphamide as an adjunct to steroids based on similar outcomes and a better side effect profile. Plasmapheresis may also be considered in severe cases!
This morning, we continued our joint Global Morning Report tradition with our sister institution in Maputo, Mozambique. One of our stellar second year residents, Dr. Natalie Prussak presented a great case of euglycemic DKA thought to be secondary to SGLT-2 inhibitor use. The patient was a middle aged female who had presented with anorexia, nausea/vomiting, abdominal pain, and was found to have an elevated anion gap metabolic acidosis, ketonuria, and glucosuria, although with a relatively normal serum glucose. We discussed the patient’s mixed acid base disturbances with the use of anion gap calculations, Winter’s formula calculations, as well as delta-delta ratios to determine whether there were secondary respiratory and non-gap acid base disturbances.
We then discussed the physiology of ketogenesis and its basic mechanisms, as well as how these pathways are dysrupted in the setting of stress, infection, or absolute insulin reductions.
We then discussed basic mechanisms of SGLT-2 inhibitors, their reported benefits, and adverse effects. Schafer Boeder was our Endocrinology expert discussant who reminded us that the fundamental balance in maintaining homeostasis was the balance of insulin to glucagon, and that decrements in insulin or increases in glucagon would preferentially shift the balance in favor of ketogenesis. In certain scenarios such as infection/stress, diminished beta-cell function, or use of SGLT-2 use, the balance is tilted in favor of greater glucagon production from pancreatic alpha-cells, diminished insulin secretion from pancreatic beta-cells, and therefore can set the stage for the development of Euglycemic DKA.
Thank you Dr. Prussak for a fantastic case presentation, and Dr. Schafer Boeder for this expert input. Thank you to our partners in Maputo, Mozambique for joining in!
Today our wonderful 2nd year resident, Dr. Hemali Batra-Sharma, who is currently in Mozambique, presented an interesting case of a young woman in her late teens who presented with fever and weight loss and volume overload and found to be pancytopenic, with cervical lymphadenopathy, hepatomegaly and a pericardial effusion. Fine needle aspiration of the lymph node was positive for granulomatous features. We went through our diagnostic schema for granulomatous disease and came up with good infectious, autoimmune and miscellaneous causes. The patient ultimately got treated empirically for TB pericarditis, given it’s prevalence in Maputo, but only had partial resolution of her symptoms. Dr. Batra-Sharma therefore asked for our input in other possible differentials and for any additional work-up that they should get. Our infectious disease expert, Dr. Schooley was able to give his additional insight and informed us and the team in Maputo that this seemed consistent with possible TB pericarditis, but that a bone marrow biopsy would be helpful to rule out other causes, specifically lymphoma.
Thank you Dr. Batra-Sharma for an interesting case and to Dr. Schooley for your teaching!
Today our colleagues from Maputo Central Hospital presented to us an interesting case of a young woman who had no notable past medical history who presented with lower extremity weakness for about 2 months, and was found to have a subungual lesion on her hand, palpable cervical lymphadenopathy, and 1/5 strength in her legs (with no sensory deficits). Work-up further revealed a profound AKI, anemia, and markedly elevated LDH. Biopsy of her lymph nodes ultimately revealed metastatic melanoma. We were reminded of the various types of malignant melanoma, the importance of depth of tissue invasion in staging (Breslow scale) and were given a overview of the treatment options available.
We also discussed as part of our differential fungal infections and pondered which ones are most prevalent.
Today we had a case of a man in his 30’s who came in with shortness of breath and chest pain with exertion and found to be volume overloaded, with labs and exam concerning for pericarditis. He had a vague history of joint pain for 5 years that he ignored and but was found to have symmetric polyarticular joint swelling, pain and subcutaneous nodules highly concerning untreated rheumatoid arthritis! His RF and anti-CCP ab were quite elevated, and he was ultimately diagnosed with constrictive pericarditis as a sequelae of his arthritis.
Dr. Corr, our expert discussant from Rheumatology, reminded us that Rheumatoid Arthritis can be diagnosed largely from a careful history and physical alone. Remember to check about smoking history as it is a large risk factor, and counsel about cessation if the patient happens to be a smoker! Flares can be treated with steroids, but first line therapy is methotrexate, with other non-biologic and biologic DMARDs as adjunct therapies. Our patient ultimately had improvement of his pericarditis symptoms with diuresis, colchicine and steroids and methotrexate.
This morning, we conferenced with our colleagues in Maputo, Mozambique and learned how to evaluate foot and ankle pain in the outpatient setting. Dr. Kusuma Pokala presented an exciting case this morning of an atypical presentation of ankle and foot pain initially misdiagnosed as gout after the patient was seen in an urgent care clinic. An x-ray demonstrated no significant abnormalities, however an MRI was performed given the patient’s persistent pain, which revealed an infiltrating mass in the cuboid bone, consistent with malignancy. Pathology of the lesion revealed Diffuse Large B-Cell Lymphoma!
There were several teaching points from this morning including a general review of the anatomy of the foot and ankle and developed a thorough differential for pain for the ankle as well as the midfoot. Then, our expert discussant Dr. James Hubbard from the Orthopedic Surgery department demonstrated key physical exam maneuvers on a lucky volunteer, Dr. Shannon Devlin!
Finally, we reviewed the Ottawa Foot and Ankle rules, which help determine when it is appropriate to obtain radiographic imaging.
Thank you to to Dr. Pokala for a great case and to Dr. Hubbard for his expert input!
Today we heard from our colleagues in Maputo about the case of a 50yo man who presented with 4 days of fever, dyspnea, dry cough, malaise and abdominal pain. On exam he was tachycardic, had a low grade fever and tachypnea. He was noted to be cachectic with a systolic and diastolic murmur. On his labs he had a leukocytosis, microcytic anemia, low albumin and HIV testing was positive. He had a blood culture that grew coag negative staph. They did an echocardiogram which demonstrated a vegetation on the aortic valve. As a reminder the Duke criteria are below. This is how we diagnose endocarditis, but there are a few details that stand out about this case and highlight some of the differences in clinical practice. First, the patient reported having had 4 days of symptoms which might initially seem unusual for endocarditis however as Dr. Schooley pointed out, many people in Maputo will tolerate symptoms for a long time