HIV for the Internist!

Dr. Spencer mixed up Noon Report today and educated the VA residents about HIV, anti-retrovirals, and special health care maintenance needed for patients with HIV.

Screening for HIV is indicated at least once for all patients between ages 13 -65 (CDC and USPTF) and after any high risk behavior or exposure. For HIV screening, we start with the 4th generation Ag/Ab Immunoassay which becomes positive much more quickly than the traditional western blot.

 

Don’t forget that Antigen/Antibody positivity takes~17 days. If high clinical suspicion for acute HIV, get a HIV viral load/PCR.

If a patient comes in with a positive home POC test you should still start the algorithm at the beginning with Ag/Ab immunoassay.

 
 
 

 
 

NRTIs:

Tenofovir: side effects include renal dysfunction, osteoporosis

Abacavir: requires HLAB5701 testing due to risk of hypersensitivity reaction

Emtricitabine: side effects include dyslipidemia

NNRTIs:

induces CYP 2A which can interact with Keppra

Efavirenz: neuropsychiatric side effects

Rilpivirine: cannot be started when VL >100K; cannot use with PPI (requires acid for absorption)

Protease Inhibitors and Boosters (ritonavir, darunavir, atazanavir)

CYP inhibition:

  • can increase statin levels and cause myopathy and rhabdomyolysis

  • inihibit steroid metabolism which can cause iatrogenic Cushing’s

  • side effects include dyslipidemia

Integrase inhibitors (raltegravir, dolutegravir)

  • New data questioning potential for neural tube defects during pregnancy

  • Interacts with divalent cations (cannot take with Mg, Ca supplements)

Entry Inhibitors:

Maraviroc: requires tropism testing

Thanks Dr. Spencer!


References:

•Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382(9903):1525–1533. doi:10.1016/S0140-6736(13)61809-7

•Branson BM et.al Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

 
 

Terminal Ileitis!

Dr. Tyler Wells presented a great case at noon report making us all scratch our heads and realize the importance of recognizing anchoring bias.

A 26 year old man presented with 4 weeks of RLQ pain, nonbloody diarrhea, fever and weight loss. He had no history of immunosuppression or clear exposures. He had a CT scan showing mass-like wall thickening of the terminal ileum concerning for cancer. This lead to to an extensive work up including a colonoscopy with biopsy showing inflammation but no malignancy. He had a repeat CT weeks later which showed complete resolution of inflammation. His diarrhea had also resolved. In reviewing the history, his course fit best with Yersinia ileitis (though he never had stool studies to confirm).

This led to a vibrant discussion about the differential for terminal ileitis. Our beloved Program Director, Sima, provided us with her short differential for ileitis. Also see this article (Facing Terminal Ileitis: Going Beyond Crohn's Disease) for a more extensive discussion on the differential.

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Is There a Doctor On Board?"

The flight attendant’s voice crackles over the speakers, “Is there a doctor on board?!” You, a six-month-old intern, squirm in your seat, having an identity crisis. Do I qualify? Should I volunteer? What if I don’t know what to do? What if I do something wrong? As newly minted physicians, how equipped and/or comfortable are we when facing an in-flight emergency?

A huge thanks to Dr. Riana Wurzburger for addressing the nuts and bolts of in-flight emergencies, something we rarely discuss but are likely to face!

The Stats:

  • 1 medical emergency in every 604 flights… occurs on a daily basis!
  • Mortality Rate: 0.3% (mostly cardiac arrest)
  • Aircraft Diversion: 7%
  • Resolved before landing: 31%
  • Transported to hospital on landing: 37%, Admitted: 9%
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Do I have to respond?

We are not legally required in the US, but most of us will feel ethically compelled to respond. Interestingly, the captain and flight crew make the final decision about whether or not they will allow you to provide care (or give you access to the medical kit).

Who’s on my team?

  • All flight attendants are trained in CPR
  • All domestic airlines contract with ground-based medical consultation services

What do I have?

Campion EW. In-Flight Medical Emergencies during Commercial Travel. NEJM 2015.

Campion EW. In-Flight Medical Emergencies during Commercial Travel. NEJM 2015.

What do I do? Follow your instincts! And consider the table below 😊

Campion EW. In-Flight Medical Emergencies during Commercial Travel. NEJM 2015.

Campion EW. In-Flight Medical Emergencies during Commercial Travel. NEJM 2015.

Amazingly, this topic was just published in JAMA last month with handy dandy cards for approaches to the most common in-flight chief complaints! Check it out here, and print them out with your next boarding pass!

Adventures in "Family" Medicine*

*pun courtesy of Dr Jared Huber

“Will you check out this mole?” ~Uncle Harold

“I get dizzy when I stand up, but only passed out twice. Should I go to the ED?” ~Cousin Jim

“I ran out of my nausea medicine and feel terrible. Can you write me a small refill?” ~Sister Sue

We’ve all been there…

Today Dr Huber hit us with a one-two punch: an exciting medical case and also an expose into the realities and challenges of providing medical advice and care to our family members.

Shared with the permission of his family member, Dr Huber took us on a tour of abdominal pain and bloody diarrhea, ultimately and unexpectedly caused by a “soft-ball sized” sigmoid lipoma. The work up and management of this case was through the eyes of Dr Huber, by proxy through another family member, over phone calls and text messages, complicated by the fact that the patient did not have insurance (at least until half way through the case). What fun!

To help guide Dr Huber—and in fact all of us—for inevitable future situations like this, we share below this article from the Annals of Internal Medicine (written by OHSU faculty, too boot!).

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Guide to the Incarcerated Patient

Guidelines to help with the management of an incarcerated inpatient

Guidelines to help with the management of an incarcerated inpatient

Dr. Eddie Maldonado led us through a fascinating case on Monday that touched on multiple medicolegal and social themes that are encountered on the wards. We were also joined by two representatives from our wonderful OHSU social work team who assisted answering questions about complex issues.

Incarcerated patients, when admitted to our services, have certain considerations, rules, and legal protections that we should keep in mind. Remember, implicit and explicit biases by the entire care team must be carefully considered while administering treatment for this vulnerable populartion, and their incarcerated status can change (and often does!) during the course of a hospital stay.

Thank you, Eddie!

Flozin down that river of knowledge: a wild case of undifferentiated shock!

This afternoon Dr Cara Levin brought us on an exciting journey of a middle aged man with a significant cardiovascular history (prior CABG, DES, TAVR) who was transferred to OHSU for ongoing management of shock initially felt secondary to acute GIB and acute hypoxic respiratory failure, who, when presenting to our institution, demonstrated difficult to explain labs: significant mixed AG and non-AG metabolic acidosis with respiratory acidosis, profound neutrophil predominant leukocytosis (to the 50,000s), mildly elevated lactate and then stable Hg.

What was the cause of his shock if we now couldn’t blame it on hypovolemia from his GIB bleed? Could it be cardiogenic? Was he septic? Were his new vent settings causes obstruction?

We turned to the lab abnormalities we did observe in search of other clues for our unifying diagnosis, namely… his acid base status!

In true internal medicine form, we broke down those labs in a step-wise fashion. Find below a helpful diagram courtesy of Dr Joel Topf (@kidney_boy), as featured on the hit IM podcast, “The Curbsiders”.

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Through these steps we arrived at our multifactorial mixed AG and non-AG metabolic acidosis with respiratory acidosis and grew our differential through expoloring causes for a MAGA (metabolic anion gap acidosis) with the helpful mnemonic “Goldmark”.

goldmark 2.jpg
goldmark 2.jpg

In this case, it turns out that our patient had been on Empagliflozin, an SGLT-2 inhibitor agent used in management of type 2 diabetes. While the SLGT-2 inhibitors have shown great promise in terms of reducing important cardiovascular outcomes in patients at high risk fo CV events (like our patient!), they unfortunately have a known side effect of increased risk of euglycemic DKA.

Euglycemic DKA can present with an MAGA, leukomoid reaction, and elevated lactate, like this patient. More so, acidosis is a direct cause of hypotension and shock. Per one source " Cardiac contractility and cardiac output are reduced and arterial vasodilatation develops, which contributes to the development of hypotension". (source below) After appropriate treatment with insulin and glucose, this patient’s gap closed.

In full disclosure about this case, although his labs have improved, the etiology of his initial hypotension and shock picture is not yet clear. This is, however, often the case in medicine, and shock in particular, that a single, clear, elegant explanation doesn’t exist. And as such, we again thank Dr Levin for this honest and exciting case that allowed us to walk down the often confusing paths of shock and its attedant management in a real “choose your own adventure” fashion.

Citations: -https://img.ma-shops.com/hild/pic/image01646.jpg -https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/4eb58c5284bc04a8a9c4325f003add3d36b4e18a/7-Table2-1.png -https://thecurbsiders.com/show-notes/88-acid-base-boy-bands-grandfather-clocks-joel-topf-md -https://www.medscape.org/viewarticle/718583_6

Adult Henoch-Schonlein Purpura

Dr. Kiefer presented a fascinating case of Henoch-Schonlein Purpura presenting in a patient with a complex medical history who received antibiotics and presented with new renal failure, unique “palpable purpura” rash, and hypotension. While more common in pediatric populations, HSP occurs in adults as well, and can be a result of drug reaction. While a trigger is only found in a minority of patients, in addition to medications, triggers for adult onset HSP can include infections.

representative image courtesy of  Brown EM res blog

representative image courtesy of Brown EM res blog

We used this as an opportunity to review our most commonly discussed vasculidities. Please note that this below chart is not meant to be exhaustive! It may however be useful for board prep or when thinking of a differential when a vascular inflammatory process is considered.

schema courtesy of your friendly ohsu im chief resident

schema courtesy of your friendly ohsu im chief resident