Garden Variety Pulmonary Embolism... should we worry about CIN?

Today Dr. Hegarty presented a case with the assistance of some esteemed colleagues on "boring old garden variety pulmonary embolism...sorry everybody." It was a nice opportunity for review and discussion of some new literature.

  1. Bedside ultrasound is highly operator dependent but abnormal findings are generally quite specific, if not sensitive.
  2. If someone has a Wells Score of 0, don’t forget that they may actually have a Wells Score of 3. Remember the Wells Score criteria and that your own suspicion sways the score by 3 points!
  3. The risk of CIN from intravenous contrast-enhanced CT scans is minimal and can be extremely difficult to detect. So, do not delay or defer a highly indicated study due to fear of CIN. This year our Emergency Medicine colleagues published Risk of Acute Kidney Injury After Intravenous Contrast Media Administration and Acute Kidney Injury After Computed Tomography: A Meta-analysis which call into question the entity of CIN.

When our map is incomplete: A case of HSV Esophagitis

... In that Empire, the Art of Cartography attained such Perfection that the map of a single Province occupied the entirety of a City, and the map of the Empire, the entirety of a Province. In time, those Unconscionable Maps no longer satisfied, and the Cartographers Guilds struck a Map of the Empire whose size was that of the Empire, and which coincided point for point with it. The following Generations, who were not so fond of the Study of Cartography as their Forebears had been, saw that that vast map was Useless, and not without some Pitilessness was it, that they delivered it up to the Inclemencies of Sun and Winters. In the Deserts of the West, still today, there are Tattered Ruins of that Map, inhabited by Animals and Beggars; in all the Land there is no other Relic of the Disciplines of Geography.
— "On Exactitude in Science", Jorge Luis Borges, A Universal History of Infamy

Today Dr. Chapa presented a perplexing case of a young otherwise healthy male who presented with esophagitis NOS. In time, he was found to have HSV esophagitis without evidence of being immunocompromised.

Dr. Chapa offered a way to think through situations that don't fit one of our classic illness scripts.

  1. Consider that there are 2 things happending that were mistkan for a single phenomenon. (Hickam's dictum states that a patient can have as many diagnoses as they choose vs. Occam's razor states that the simplest explanation is most likely)
  2. You may be dealing with something "very strange". This may be a new phenomenon (remember the emergence of AIDs, etc) OR your knowledge base is incomplete.
  3. Consider that your information is "bad". Remember that no test is perfect and to think about sensitivity, specificity, positive predictive value and negative predictive value as appropriate.

HSV esophagitis in immunocompetent patients is noted in case reports. The American Journal of Gastroenterology commented on this in 2000 where they described 38 cases. Of those cases,

  • Most commonly presents as 3-21d of fevers, sore throat prior to esophagitis symptoms
  • 20% with oral lesions, 2 with genital, 3 with hand/foot vesicles
  • Classically a distal esophagitis with volcano-like ulceration
  • Immunocytochemistry 83% sensitive
  • Tissue viral culture 96% sensitive
  • Symptoms remit in 2-20 days
  • Antivirals used in 26%, no real ability to determine efficacy

Post-Obstructive Pneumonia

Today Dr. Hobbs presented an interesting case of post-obstructive pneumonia presumably from external compression from calcified lymphadenopathy from prior granulomatous disease. There were several take away points:

Transudate vs. Exudate: remember Light's Criteria

  • Pleural Protein/Serum Protein >0.5
  • Pleural LDH/Serum LDH >0.6
  • Pleural LDH >2/3 the upper limit of normal

Chest Tube Placement: indications according to ATS guidelines

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Broncholiths: calcified material within the lumen of a bronchus. Can be a result of histoplasmosis, TB or a calcified endobronchial tumor. Recently discussed in NEJM (Williams K, Swanson K. N Engl J Med 2017;377:e4)

Tuberculosis In Oregon: TB cases from Micronesia continue to be diagnosed in Oregon. This includes Guam, the Marshall Islands, the Federated States of Micronesia and the Mariana Islands. 4 cases have been reported in 2017 thus far. And, they are typically very ill at diagnosis. Remember to consider TB on the differential!

  • Remember if diagnosing TB from a pleural effusion, the sensitivity and specificiy of of pleural fluid stain and culture is dismal (staining less than 5% and culture + 20-30%). The test of choice would be pleural fluid adenosine deaminase (ADA) measurement which is >60U/L is 95% sensitive and 96% specific for TB.

Global Health Case!

Dr. Kathy Wunderle presented a very interesting case of a middle aged cachetic male with a history of HIV not on HAART without recent CD4 count who presented with a progressive R groin mass, acute non-productive cough, night sweats and weight loss who was found to have non-painful, fixed bulky lymphadenopathy, hypoxia with diffuse crackles and progressive encephalopathy. In addition, the labs that were able to obtained were pertinent for a Na of 114, Cr of 3.3, WBC 30.2, plt 48, elevated LFTs and albumin of 1.3. Eventually, a biopsy of his R groin mass showed MAC and he was also treated for pulmonary TB.

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Learning Points:

  • One of the largest take away points from this conference included the management of this gentleman's medical conditions without our conventional resources available to us in the United States. Some examples of resource limitations included:

    --once daily labs in a patient at risk for rapid overcorrection of sodium

    --inability to obtain a basic chest xray to evaluate his hypoxia

    --lack of access to advanced imaging such CT head

    • Kathy had excellent learning points including:

      -- The differential for mass/lymphadenopathy in a patient with HIV is broad, and includes lymphoma, infection, and Kaposi Sarcoma

      -- The incidence of TB is higher in HIV infected populations, and they require different prophylaxis than non-TB infected patients (i.e. always given Bactrim ppx)

      -- In patients with untreated HIV and TB, start HAART within 2 weeks

  • She reviewed a systematic review and meta-analysis published in 2015 in the Annals of Internal Medicine which showed a survival benefit of early ART in HIV-infected adults with newly diagnosed TB for those with CD4 count <50. data-preserve-html-node="true"

Cavitary Lung Lesion

Dr. Vanderschuur presented an interesting case of a chronic progressive nonproductive cough found to have RUL cavitary parenchymal lung lesion concerning for lung abscess. On bronchoscopy, he was found to have a piece of food lodged in a large airway proximal to the abscess. Some takeaways from Dr. Vanderschuur:

  • Lung abscesses are typically a result of polymicrobial anaerobic infection
  • Immunocompromised individuals also at risk for pseudomonas, other gram negative bacilli, norcardia, TB or fungal
  • Chronic systemic disease symptoms are usually present (weight loss, night sweats and anemia)
  • Imaging usually diagnostic (except in atypical presentations or immunocompromised) and are usually in dependent sections of the lung. Can be helpful for ruling out empyema as well.
  • If atypical presentation or immunosuppressed, will likely need bronchoscopy to rule out more esoteric etiologies
  • There are no standard guidelines for how long to treat lung abscesses, but most recommend serial imaging for resolution and typically will need 4-12 weeks of antibiotics.
  • Patients with clear signs/sxs of lung abscesses can be diagnosed and treated with imaging alone, however, if the presentation is atypical or patient immunosuppressed, will likely need bronchoscopy and rule out of other diagnoses.
  • Procalcitonin can be a useful tool in acute respiratory illnesses to decide on whether to start antibiotics and can help in duration of antibiotic exposure.
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