IM Residency Council End of the Year Update!

The Internal Medicine Residency Council (IMRC) has been working hard this past year, and we want to acknowledge all their hard work! See the list below of their accomplishments.

If you have an idea to improve the residency, reach out to the IMRC members.

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**IMRC Members:**

Executive Director: Matt O'Donnell

Assistant to the Executive Director: Mareli Coetzer, Joel Burnett

Secretary: Kelly Jensen

Head of Volunteerism: Kelsi Manley

Head of Big Sib/Lil Sib Program: Cassie Mullen

Social Event Coordinator: Ashray Maniar

Rising R2s: Mareli Coetzer, Kelly Jensen, Alice Kehaya, Cassie Mullen, Eric Schmidt, Derrick Tao, Yoni Taylor

Rising R3s: Joel Burnett, Justin Lewis, Eddie Maldonado, Ashray Maniar, Kelsi Manley, Matt O’Donnell, Francis Phan, Namisha Thapa

Acute Liver Failure and Hyperferritinemia!

Dr. Gardner presented a great case of a man who was recently started on steroids that developed diffuse weakness and vesicular facial rash. His labs revealed acute liver failure (hepatocellular pattern with AST and ALT in 10,000s), thrombocytopenia, and a ferritin of 15,000! Our residents discussed the differential for transaminases greater than 1000, and our graduating resident, Dr. Jared Huber, gave an excellent mneumonic of "VITAMIN-C" to help us rememeber.

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We also were reminded of causes of elevated ferritin, including disseminated fungal and viral infections. Because of the severity of this man's presentation, numerous medical teams were consulted. The diagnosis of HLH was entertained, but the patient did not meet criteria, and BM biopsy was negative. Ultimately, he was found to had disseminated HSV (confirmed with skin biopsy) causing his acute liver failure and hyperferritinemia. This case is a great reminder that when you are in a diagnostic dilemma, it can be helpful to go back to the presentation (his vesicular facial rash) and you may just find the diagnosis.

HES (Hypereosinophilic Syndrome)

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Dr. Zhou presented an interesting case of a young previously healthy female with sub-acute relapsing periarticular edema and hypereosinophilia, ultimately felt to be secondary to lymphocytic variant of HES.

She shared her ddx for eosinophilia (CHINAA)

C – connective tissue diseases, e.g. eGPA, GPA, RA, dermatomyositis, scleroderma, Sjogren’s, SLE, Behcet’s IgG-related disease, APLS, immunodeficiencies

H – helminths

I – idiopathic (HES)

N – neoplasms, e.g. AEL, CEL, CML, systemic mastocytosis, B cell lymphoma, T cell lymphomas/leukemias, solid tumors (esp. GI tract, lungs, SCCs)

A – allergies, e.g. asthma, DRESS, ABPA

A – adrenal insufficiency

HES: AEC >1500 on 2 occasions + evidence of organ dysfunction

Primary HES: Due to neoplasm/clonal expansion

Secondary: Due to other etiologies (noted above, with helminth infections being the most common) , certain solid tumors, and T-cell lymphoma. Lymphocytic variant HES is a sub-variant in this category.


Patients with primary eosinophil counts > 100K/or rapidly rising eosinophil counts should be urgently referred to hematology and started on empiric treatment (pulse dose steroids + ivermectin if strongyloides positive).

Emphysematous Pyelonephritis

Dr. Hill presented a very interesting case of a patient with history of poorly controlled diabetes and urinary retention who was initially admitted with severe sepsis due to a presumed complicated urinary tract infection. The patient’s hospital course was complicated by recurrent fevers even 48-72 hours after antibiotics were started.

Dr. Riquelme reviewed a nice framework for thinking about causes of ongoing GU infections by thinking through the anatomy of the GU tract:

  • Prostatitis

  • Unresolved bladder outlet obstruction

  • Nephro/ureterolithiasis as a nidus of infection or causing pyonephrosis

  • Pyelonephritis

  • Perinephric abscess

Thanks to Dr. Hill’s case, we also have one more to add to our differential:

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Hypercalcemia

Dr. Brook Pittenger presented a case of a 66-year-old veteran with history of hypothyroidism and episodic conjunctivitis who presented with symptomatic hypercalcemia (myalgias, constipation, AKI), and bilateral hilar LAD concerning for sarcoidosis.

We reviewed a hypercalcemia framework (taken from Frameworks for IM by Dr. Andre Mansoor) and targeted workup/management based on this framework.

Hypercalcemia Framework.JPG

Patient was treated with IVF. Calcitonin, bisphosphonates and steroids deferred on admission. Per Dr. Pittenger’s review of the literature, bisphosphonates may be beneficial for long term remission (cases series 3 patients, Arch Osteoporos 2017). Patient was subsequently started on prednisone and is symptomatically improving with down trending serum Ca++. Bronchoscopy and biopsy obtained today for confirmation. 

A definitive diagnostic test for sarcoidosis does not exist. Diagnosis requires: compatible clinical and radiographic manifestations, exclusion of other diseases that may present similarly, histology showing noncaseating granulomas. The main exceptions to the need for biopsy are the presence of bilateral hilar adenopathy in an asymptomatic patient who can be monitored and the presentation of Lofgren’s syndrome (fever, erythema nodosum, arthralgias and bilateral LAD). 

 

 



Win of the Week: TOAD Day!

Last Friday, we surprised our AMAZING office staff with Total Office Appreciation Day, or T.O.A.D. Day! This team is truly what makes our residency program function on a day to day basis - my mind is boggled whenever I look at one of their many excel spreadsheets, clinic schedules or email inboxes! Dena, Jess, Lynn, Marcie, and Staci - thank you for another incredible year, and for doing all that you do to make our lives run smoothly!

Last Friday, we surprised our AMAZING office staff with Total Office Appreciation Day, or T.O.A.D. Day! This team is truly what makes our residency program function on a day to day basis - my mind is boggled whenever I look at one of their many excel spreadsheets, clinic schedules or email inboxes! Dena, Jess, Lynn, Marcie, and Staci - thank you for another incredible year, and for doing all that you do to make our lives run smoothly!