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!
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).
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! firstname.lastname@example.org
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.
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!
At Noon Teaching Conference today, PGY-3 Emily Margolin and Nephrologist Dr. Tyler Woodell guided us through the case of a young woman who presented with significant peripheral edema and was found to have urinary excretion of 16 g of protein per day and hypoalbuminemia of 1.1 g/dL, consistent with nephrotic syndrome. Kidney biopsy revealed AA amyloidosis. The patient also reported chronic nausea/vomiting and diarrhea and underwent EGD/colonoscopy, with biopsies from stomach, duodenum, and colon showing amyloidosis. Her AA amyloidosis was ultimately attributed to chronic inflammation from IVDU and related bloodstream infections.
We discussed the five main causes of nephrotic syndrome: 1) minimal change disease, 2) focal segmental glomerulosclerosis, 3) membranous nephropathy, 4) amyloidosis, and 5) diabetic glomerulopathy. We also discussed five types of systemic amyloidosis: 1) AL, 2) AA, 3) ATTR wild-type, 4) heritable ATTR, and 5) dialysis-related amyloidosis. Of these five, AL and AA amyloidoses most often involve the kidney.
Today at Hillcrest, we discussed a patient presenting with Gaucher’s disease and how to approach diagnostic uncertainty when face with a common presenting symptom in a patient with a complicated past medical history. We practiced different ways we could approach diagnostic uncertainty to help reach the best outcome with the patient.
Today for Noon Conference Anjali Kumar (PGY3 and future Chief), presented a case of malaria in a migrant patient. We were joined by Dr. Annie Cowell (Infectious Disease/APD), who taught us some key pearls such as:
- Fever in a recent traveler should always trigger malaria
- Determine if the patient has complicated or uncomplicated malaria–treatment is different
- If P. viva, don’t forget to treat the liver hypnozoites
- Call the ID fellow overnight! Malaria is an emergency!
In a joint event sponsored by AHEAD (Advancing Health Equity, Advocacy, and Diversity) and PRIME-HEq (UCSD SOM), we welcomed Dr. John Carethers to speak with us about his journey in medicine. Dr. Carethers will be starting his new role as Vice Chancellor for Health Sciences at UCSD in January. Dr. Carethers attended Wayne State University School of Medicine, he completed residency at Massachusetts General Hospital, followed by fellowship in Gastroenterology at the University of Michigan. Prior to his new appointment, he has served as the University of Michigan, Chair of Internal Medicine. He was the PI for the SDSU/UCSD Cancer Center Comprehensive Partnership U54 grant which addresses cancer disparities. He has also served as chair of the Minorities in Research Council of the American Association for Cancer Research and contributed the inaugural and subsequent AACR Cancer Health Disparities Report and its presentation to the United States Congress.We were lucky to hear about his journey in medicine and research, about the role of mentorship, honest evaluation and work ethic. We were joined by faculty, staff, fellows, residents and medical students from Internal Medicine, Pediatrics, Ophthalmology, Gastroenterology, PCCM and Cardiology. Our next AHEAD event will be January 10, 2023!
Stacy Han (PGY3) and Dr. Darcy Wooten (ID and PD of ID fellowship), walked us through a fascinating case of necrotizing pneumonia for noon conference. We talked about empiric antibiotic regimens and this patient had a penicillin allergy and how serial imaging can be useful.
- Identify the pathogen
- Do not try to tap unless there is an empyema or abscess
- These patients are very sick and may need surgery.