How to Not Miss Necrotizing Fasciitis!

Today Dr. Sulpizio presented a thrilling case of a young poorly-controlled diabetic male who presented with acute onset of rapidly progressive facial swelling refractory to steroids, found ultimately to have the dreaded necrotizing fasciitis! Though a surgical diagnosis, it is crucial that we as internists not miss this! The table below is from an excellent summary from NEJM – Necrotizing Soft-Tissue Infections from Dec 2017. It details common pitfalls in diagnosis, such as being falsely reassured by imaging that shows edema only without frank gas or abscess (our major pitfall today!).

nec fasc snip 3.PNG

Take Home Points:

  • Early recognition is VITAL.
  • There are two types of necrotizing soft tissue infections.
    1. Type I (polymicrobial) – Enterobacteriaceae, bacteroides, clostridium, GAS
    2. Type II (monomicrobial) – GAS, Staph aureus
  • Do NOT rely on the LRINEC score (performs poorly in external validation studies).
  • Surgical intervention is the only definitive diagnostic and therapeutic approach.
  • Include IV clindamycin with empiric antibiotic coverage to counter toxin production.
 Shout out to MedComic for this hilarious graphic!

Shout out to MedComic for this hilarious graphic!

WIN OF THE WEEK: Drs. Iossi and O'Glasser

Our very own Associate Program Director for Ambulatory, Dr. Katie Iossi and Assistant Program Director for Social Media and Scholarship, Dr. Avital O'Glasser both made a splash this week!

 Dr. Iossi was featured in the Alliance for Academic Internal Medicine (AAIM) "Connections" Newsletter. Read all about it  here .  Dr. O'Glasser, our local academic social media expert, gave a Department of Medicine Grand Rounds presentation on one of her topics of expertise, Academic Medicine's use of Twitter. Her talk and accompanying " Tweetorial " (so meta!) quickly went viral, gaining tremendous feedback across social media as the "gold standard" for discussions about academic use of social media.  Congrats to our fantastic faculty!

Dr. Iossi was featured in the Alliance for Academic Internal Medicine (AAIM) "Connections" Newsletter. Read all about it here.

Dr. O'Glasser, our local academic social media expert, gave a Department of Medicine Grand Rounds presentation on one of her topics of expertise, Academic Medicine's use of Twitter. Her talk and accompanying "Tweetorial" (so meta!) quickly went viral, gaining tremendous feedback across social media as the "gold standard" for discussions about academic use of social media.

Congrats to our fantastic faculty!

The Big Man speaks on Liddle-Man’s!

Today Dr Grovenburg (the “big man”) presented a show stopping case of impressive hypokalemia (K 1.6) in an older woman who was also recently found to be hypertensive and demonstrated a significant metabolic alkalosis.

What a great presentation for the classic triad often seen in mineralocorticoid excess of: 1) Hypokalemia 2) Hypertension and 3) Metabolic Alkalosis.

MCE.jpg

The causes of mineralocorticoid excess are further broken down, as seen in the table below.

AME.PNG

In the case of our patient, who was found to have LOW renin and LOW aldosterone, the jury is still out if her diagnosis is Apparent Mineralocorticoid Excess or Liddle’s Syndrome. Worth note, licorice can also do this, but not your average twizzlers… the real kind. Below is a nice compare and contrast of these two conditions (well three conditions—there is a shout out to licorice).

Liddle.PNG

Pop Quiz: Mind the (protein) Gap

Below you will find a brief pop quiz in follow up to Dr Doan's wonderful case of Multiple Myeloma presenting as profound AKI (Cr 8!).

1) What two labs do you need to identify a protein gap?

2) Name two infectious causes of an elevated protein gap?

3) What is the most common presenting symptom of the CRAB criteria?

4) What are the two "magic numbers" for abnormal values of the CRAB criteria?

5) What is the "money" finding of multiple myeloma on peripheral smear?

popquiz.PNG

ANSWERS:

1) serum protein - serum albumin = protein gap 2) HIV, Hep C 3) Bone Pain (CRAB is written in least to most common order of symptoms: #1 bone pain, #2 renal failure, #3 anemia, #4 hypercalcemia) 4) 10 and 2! (Ca > 10.2, Hg < 10, sCr >2) 5) Rouleax Formation (French for "cylindrical roll of coins")

How'd you do?

Be Still My Heart... A Case of Type I NSTEMI

Dr. Hegarty presented a classic bread & butter case today of an older man with multiple CV risk factors who presented with acute typical angina, found to have diffuse ST depressions on EKG and elevated troponin, concerning for a Type I NSTEMI.

There are many juicy learning points from this case, but let’s start with a review of the spectrum of ACS!

ACS spectrum snip.PNG

Pearls from Dr. Hegarty:

  • STE in aVR with diffuse ST depressions is a pattern we should recognize! The STE is reciprocal to diffuse ischemia, indicating left main CAD or multivessel disease. If you see this pattern, your patient may need a CABG!
  • One of the most important aspects of initial NSTE- ACS care is TRIAGE!

    • Criteria for Urgent Cath (Cath now!): STEMI, hemodynamic instability, electrical instability, pain not controlled with maximal therapy
    • Criteria for Early Cath (Cath within 24h): High risk patients with GRACE > 140, TIMI 2+, impressive EKG changes or troponinemia

Our most recent reference for management of NSTEMI is the 2014 AHA/ACC guidelines. Click here for a thorough and scintillating read, or see below for summary tables regarding initial management (nitrates/opiates, BBs, CCBs, statins) and antiplatelet/anticoagulant recommendations (aspirin, clopidogrel, heparin).

ACC guidelines 1 snip.PNG
ACC guidelines 2 snip.PNG

Weekly Evidence Update 7.30.18

The Impact of Listening to Music During a High-Intensity Exercise Endurance Test in People with COPD (Chest 5/2018).

Pulmonary rehabilitation is a key non-pharmacological component of COPD management. This is reflected in the most recent GOLD 2018 guidelines, which note pulmonary rehabilitation, “improves symptoms, quality of life, and physical and emotional participation in everyday activities”. While this may not carry the mortality sparing effects of smoking cessation and supplemental oxygen, pulmonary rehabilitation offers the opportunity to improve the quality of life of patients. However, pulmonary rehabilitation can be limited due to dyspnea. A 2015 meta-analysis in CHEST demonstrated improved components of the 6-minute walk test when participants listened to music. The authors of the above study evaluated the impact of self-selected music on participants dyspnea and symptoms during endurance walking tests. Patients were tested at a “usual walking” pace and “fast walking” pace. Music genres available included pop, classical, country and western, and big band. The selected music had a tempo of 90-120 beats per minute. The authors found a significant difference in endurance time (7.0 vs. 5.9 minutes) when listening to music. There was also a significant decrease in dyspnea at the end of exercise in participants listening to music. The authors also noted “an increase in the degree of patient calmness was evident with music listening”.

Find the article here

Take Home: Music therapy for patients with stable COPD can lead to small improvements in both endurance time and dyspnea. This may be due to music serving as a distraction from the sensory effects of dyspnea. More work is indicated to clarify the role of music in symptom management amongst patients with an acute exacerbation of COPD.

Centenarians’ End-of-Life Thoughts and Plans: Is Their Social Network on the Same Page? (JAGS 2018)

End of life (EOL) discussions are a key component of the therapeutic relationship between providers, patients, and caregivers. It is often in the most crucial of times that caregivers must advocate on behalf of their family members or friends regarding therapeutic and symptomatic based treatment decisions. In Oregon, we are fortunate to have fantastic geriatric physicians who emphasize the importance of end of life planning. The authors of the above study sought to evaluate the amount concordance or discordance between centenarians and their proxy informants regarding EOL thoughts and planning. The authors found that only about 50% of the centenarians had thought about EOL. Additionally, 81% of proxies thought the centenarian had arrangements for EOL, when only 58% of centenarians had done so. However, the authors note this latter percentage may have been falsely lower in the centenarian group due to potential recall bias. Regardless, this interesting study highlights the persistent gaps between patients and caregivers amongst our oldest living individuals. Fortunately, a great resource- The Conversation Project (shown to me by our very own Dr. Eckstrom!)- to assist in starting this discussion with patients and families is freely available.

Find the article here

Take Home: Despite the importance of discussing end of life planning, a large percentage of patients have not approached this topic. Moreover, this study found expectations surrounding end of life planning often differed between caregivers and patients. Providers should strive to communicate early and frequently with patients and families to identify and discuss discordant end of life expectations and goals.

When you see a bleed, think "Vit C"! (not for the reason you're thinking...)

Thank you, Ashray, for an exciting case of CMV colitis likely secondary to steroid use for alcoholic hepatitis, presenting as acute GI bleed. Although the outcome of this case was unexpected and an interesting etiology of lower GI bleed, it also provided the important opportunity to review our approach to management of acute bleeds.

So, first things first, when you know someone is coming in with active GI bleeding, your brain will probably think, “I need to give them blood”—and you’d be correct. That said, don’t forget some of the other important “to dos” that you should implement when they hit the floor. Here is a handy pneumonic to remember some of the key items.

Vit C

V- vital signs

I- IV access

T- type and cross

C-consent

Vit C.jpg

It sort of makes sense since if you have scurvy (vitamin C deficiency) you can experience easy bleeding. Get the connection? I know, sort of a stretch...

But, now you’ve implemented your “vit C” and have ensured your patient is stabilized! This means you have time to think about why they are bleeding, which leads us back to the eventual diagnosis in this case: CMV colitis.

CMV colitis presents with fever, painful, diarrhea (grossly bloody in up to 53% of patients) and is more commonly seen in the immunocompromised host. In this case, we suspected the prednisolone our patient had been on predisposed her to this infection- either primary or reactivation of a latent infection. The diagnosis was made by colonoscopy with pathology that tested positive for CMV. She was initiated on treatment with valganciclovir.

Win of the Week!

 Cheers to Dr. Phan for an incredibly creative Noon Report this week! He recruited 16 blood pressure cuffs, a doppler, a bag of straws, and the Cardiology Consult Team.&nbsp;Now that's a recipe for true learning! His session demystified the dying art of the pulsus paradoxus, adding a tangible skill to every resident's physical exam repertoire. Way to go Francis!!

Cheers to Dr. Phan for an incredibly creative Noon Report this week! He recruited 16 blood pressure cuffs, a doppler, a bag of straws, and the Cardiology Consult Team. Now that's a recipe for true learning! His session demystified the dying art of the pulsus paradoxus, adding a tangible skill to every resident's physical exam repertoire. Way to go Francis!!