MTC 1/14 – Hypoactive Delirium

Thursday morning, Brian Coburn, one of amazing second year Med/Peds residents, presented an interesting case of a 35-year-old patient who presented with hypoactive delirium. The patient’s medical history was significant for epilepsy and opioid use disorder. We started our investigation of possible causes of the patient’s encephalopathy by going through the AEIOUTIPS mnemonic of common causes of altered mental status that can be investigated with basic history, exam, labs, and imaging. Our expert discussants from the Toxicology services provided us a comprehensive overview of the approach to hypoactive toxidromes and judicious interpretation of urine tox screening. After the initial work-up was unrevealing, the team pursued additional investigation with lumbar puncture, EEG, and MRI without contrast that were also negative. The team asked our friends from psychiatry to help elucidate whether the patient’s symptoms may be due to an underlying psychiatric disorder, but the determination was made that a primary medical disease was still the most likely cause.

The patient’s condition continued to progress, and an MRI with contrast ultimately revealed acute, diffuse white matter lesions. Per our radiology colleagues, the differential for these findings included infection/post-infectious causes (viral encephalitis, acute disseminated encephalomyelitis, acute hemorrhagic leukoencephalitis), autoimmune encephalitis, and toxic leukoencephalopathy. Following a repeat LP that was negative for a broad array of infectious, autoimmune, and malignant/paraneoplastic studies, we were left with a diagnosis of opiate-induced toxic leukoencephalopathy. The disease presentation is extremely variable, ranging from minor cognitive impairment, easily confused with psychiatric illnesses, to severe neurological dysfunction. Our toxicologist reminded us that some of these findings can also be seen with potential transient, out-of-hospital anoxic episodes. While there is no proven treatment for toxic leukoencephalopathy, antioxidant therapy with Coenzyme Q10, Vitamin E, and Vitamin C has been used to treat some patients with variable results in the past. The patient received this treatment and spontaneously improved after several days of therapy.

Thank you to Brian, our expert discussants, and our residents for working through the differential of hypoactive delirium and the sequential investigations we needed to get to the bottom of this fascinating case.

Primary Care Job Opportunities!

There are many organizations currently hiring primary care doctors in the Southern California region and UCSD graduates are highly desirable candidates! If you are considering a job in primary care, please reach out to Stacy Charat, Primary Care Pathway Director for more information (scharat@health.ucsd.edu)

Examples of opportunities include:

  • TrueCare Federally Qualified Health Centers in North County, San Diego
  • St. Jude Heritage Medical Group in Orange County
  • Private Practice multi-specialty group in San Diego

MTC Shock

Today we discussed a patient who presented hypotensive from hemodialysis clinic. We reviewed causes of acute shock examining the different categories of shock including hypovolemic, distributive, cardiogenic and obstructive. We reviewed the physiology for each class of shock as outlined in the table above.

Our patient was febrile, hypotensive and with elevated JVD and muffled heart sounds on exam. We reviewed our next steps in workup to help differentiate which etiologies of shock could be contributing. Our patient was found to have a respiratory infection as well as pericardial effusion indicating a likely mixed picture of obstructive and distributive shock.

We then reviewed blood pressure supporting medication used to help treat shock and what effects each medication has on the body physiologically. Helping us to figure our next steps in managing patients with shock.

Planning on applying to fellowship?

Join us tonight, Thursday, 1/14, 6-7:30 PM – Zoom link is in your email!

Agenda for the Session:

6-6:30pm: General overview of the application timeline and steps all applicants need to take presented by Alex Cypro and Dr. Jassal. 

6:30-7:30pm: Sub-specialty breakout rooms featuring all of the specialties that you expressed interest in on a survey earlier in the year, including Cardiology, PCCM, GI, Rheumatology, Endocrinology, Allergy & Immunology, Infectious Disease, Heme/Onc, Geriatrics, and Nephrology!

JMC Afternoon Conference – Perioperative Medicine!

Today during Jacobs afternoon conference, we kicked off our Hospital Medicine Pathway Block with a session about perioperative medicine given by Dr. Bill Frederick, one of our hospitalists. We covered how to field internal medicine consults, preoperative risk stratification, and management of common post-operative issues.

We started the session with a review of some of Goldman’s Commandments for fielding a consult: be appropriately brief, be specific, provide contingency plans, and Honor Thy Turf. We spoke about the components of perioperative risk assessment, which include surgical urgency, red flag signs, surgery-specific risks, functional status, and clinical risk factors. We then discussed common perioperative cardiac complications and appropriate risk stratification (including an assessment of activity and risk stratification tools like RCRI and NSQIP). We also discussed the importance of conferring with our anesthesia and surgery colleagues with regard to preoperative medications (antiplatelets, anticoagulants, antibiotics, and others). Finally, Dr. Frederick covered common postoperative issues including lines/drains, third-spacing of fluids, NPO status, and intraoperative and postoperative medication side effects. Special thanks for Dr. Frederick for sharing his expertise in this area!

Historic Payment Wins with CMS and Congress
Wins include increased pay for office visit and other E/M codes that will result in an estimated 6% increase in total 2021 Medicare payments to internal medicine physicians.

Physicians and Patients were supported during COVID-19
Achieved financial assistance for practices; pay parity for telemedicine; Medicare regulatory requirements eased; increased funding for testing and treatment; and increased availability of PPE.

Barriers to Care, Disparities, and Discrimination in Health Care were addressed
Promoted diversity equity and inclusion, releasing “Racism and Health in the United States” policy; participated in joint arguments to protect the ACA; and opposed rules to deny access to care.

Policy Development Focus
Addressed promoting prescription drug competition, step-therapy and nonmedical drug switching, and new surprise medical billing provisions; provided recommendations to the Biden transition team.

New Vision for Comprehensive Health Care Reform was published
Envisioning a Better U.S. Health Care System for All proposes comprehensive reform of U.S. health care, the importance of which is magnified by the COVID-19 pandemic.

MTC Myasthenia Gravis

Our PGY-3 resident Lauren Haggerty and our wonderful expert discussant Dr. Konersman led us through a case of a patient who presented with shortness of breath and ptosis found to have myasthenia gravis.

We reviewed the causes of neuromuscular weakness and how to think about your differential using your neurologic exam. We narrowed our patient differential to myasthenia confirmed by positive Ach receptor antibodies.

We then reviewed myasthenia gravis which is an autoimmune disease directed against the postsynaptic neuromuscular junction. We also reviewed treatment and monitoring of acute crisis as seen in our patient. NIF and vital capacity are important monitoring tool to assess respiratory function. Treatment may include IVIG or plasmapharesis in the acute setting.

Grand Rounds 1/13: “Collaborating with the Innate Immune System to Treat Antibiotic-Resistant Superbugs” with Dr Nizet

Dr Nizet research emphasizes the important role of the innate immune system on fighting infection. Many studies focus on how various antibiotics interact with one another and can be used to find a synergistic effect. Dr Nizet argues that being agnostic about the innate immune system during these studies may be underestimating their overall effect fighting infection in vivo. Before many patients are given antibiotics in a clinical setting, they are already receiving “antibiotics” in the setting of various peptides created by the innate immune system. The effect of antibiotics on the innate immune system can have a dramatic effect on infection clearance. These are illustrated in various studies including the effect of Nafcillin + Daptomycin on MRSA. While Nafcillin does not have direct effect on MRSA when studied in non-physiologic settings, there seems to be an activation of the innate immune system with Nafcillin. The effect is increased clearance of MRSA in bacteremic patients and the basis of guidelines suggesting the combination of Daptomycin+ beta-lactams in treating MRSA bacteremia. This concept is also illustrated in MDR GN organisms and azithromycin. While we do not typically consider Azithromycin as a potent antibiotic against many GN organisms such as PsA and Klebsiella, through its activation of the innate immune system (LL37 peptides) there is potent MDR GN activity. Even non-antibiotic medications, including statins and tamoxifen, increase innate immunity effects on bacteremia. Interestingly, platelets play a vital role in the innate immune system. P2Y12 Inhibitors (Brillanta) has been shown to decrease lethal Staph aureus infection by reducing Staph aureus induced thrombocytopenia! Next steps to help more effectively fight infection and sepsis are isolating parts of the innate immune system to fight infection. Dr Nizet and his collaborators are looking specifically at Macrophage-derived “nanosponges” which have been shown to increase LPS neutralization, cytokine sequestration to treat sepsis as an adjunct to antimicrobials.

Morning Report 1/12/21

Today with Dr. Rifkin, our expert nephrology consultant, we presented a case of a 33 year old man with HIV who presented with generalized edema. He reported 3-4 days of progressive lower and upper extremity edema that was associated with nausea. We initially guided our HPI based on questions for the Big 3 causes of generalized edema: cirrhosis, heart failure and CKD/nephrotic syndrome. Our patient denied any orthopnea, DOE, PND, weight gain or shortness of breath and reported no alcohol use in the past 3 years and no history of hepatitis. On his initial exam he was found to have a macular rash on his palms and back along with 3-4 mm of pitting edema. Initial screening labs were done which showed a creatinine of 2.1, albumin of 1.3 and UA with 1+ blood and 3+protein with a TP/CR of >3.13gm/day. Given concern for nephrotic syndrome we discussed a framework for approaching this broad spectrum of diseases. To do this we divided nephrotic syndrome in primary and secondary causes and then used this list to guide further workup. In our patient this included SPEP/UPEP to rule out Multiple Myeloma, PLA2R, ANA/ANCA, C3/C4 and 24 hour urine collection, and syphilis screening. He was found to have 20gm of proteinuria a day and was diagnosed with new onset syphilis infection. Given a relatively negative screening a kidney biopsy was pursued which ultimately diagnosed him with Membranous Nephropathy (MN) based on the granular IGG deposition and sub-endothelial deposits. Since he had a negative PLA2R, he was diagnosed with secondary MN due to syphilis. Fortunately for him his creatinine downtrended and proteinuria significantly improved simply with the treatment of his infection with penicillin. Thank you to Dr. Rifkin for her participation as an expert discussant and Dr. Abushamat for bringing us this case!

Take home points:
– Consider renal, cardiac and liver causes in patients presenting with anasarca. Make sure to as pertinent questions to guide your next workup.
– When asking about supplements or medications ensure you are as specific as possible. Our patient was taking pre-workout supplements but it is important to ask about steroids. One way to as is “do you receive anything by mouth or any injections where you workout” as patients frequently deny steroid use.
– When evaluating nephrotic syndrome remember diagnosis requires >3.5gm of proteinuria/day and frequently presents with hypoalbuminemia, hyperlipidemia, and lipiduria.
– Nephrotic syndrome can be divided into primary and secondary causes which will enable you to guide your workup for potential causes of your patient condition.
– Membranous Nephropathy (MN) is the most common cause of adult onset nephrotic syndrome in caucasian males.
– MN is defined as: the deposition of immune complexes and complement components in the glomerular capillary wall and attendant new basement membrane synthesis.
– MN is strongly associated with malignancy in patients over 60 years old and requires an extensive workup if diagnosed in this age range.