Constrictive Pericarditis and PJP Pneumonia

Dr. O’Donnell presented 2 cases of dyspnea with focus on clinical reasoning.

The first case, taken from the Journal of Hospital Medicine: Clinical Conundrums, focused on an elderly man with recent diagnosis of cryptogenic cirrhosis and subacute dyspnea on exertion. This was a good case as it stimulated discussion regarding common causes of cirrhosis (which should be assessed and ruled out) before a diagnosis of cryptogenic cirrhosis can be made. Exam was notable for absent stigmata of chronic liver disease (other than ascites) and elevated JVP.

Hepatic enzymes and tests of synthetic liver function were normal. SAAG> 1.1 with elevated total protein. ECG with low voltage. Echocardiogram revealed concentric LVH without pericardial effusion or thickening. Cardiac catheterization demonstrated equalization of diastolic pressures. A cardiac MRI was subsequently obtained which revealed a severely thickened pericardium, suggestive of constrictive pericarditis.

Constrictive Pericarditis.JPG

Cardiac MRI showing thickened pericardium

Take Home Points:

Cirrhosis due to heart failure can be distinguished from other causes of ascites based on ascitic protein concentration greater than 2.5 g/dl, relatively observed synthetic function and lack of stigmata of chronic liver disease.

A patient with cirrhosis, ascites and elevated JVP should prompt echocardiographic evaluation

Cardiac magnetic resonance is diagnostic procedure of choice for certain pericardial diseases, including constrictive pericarditis

The second case Dr. O’Donnell presented was of a middle-aged man with cough, progressive dyspnea and weight loss.

Exam notable for tachycardia and hypoxemia with diffuse rhonchi on lung auscultation. Laboratory work up notable for elevated LHD. CT chest with diffuse ground glass opacificatoins. We reviewed differential for diffuse ground glass opacifications including DAH, edema, viral illness (PJP, CMV), HSP, NSIP, and UIP (the later three are typically more chronic progresses, often with fibrotic changes).

On further interview, patient was found to have risk factors for HIV. HIV screen returned positive. Patient subsequently underwent bronchoscopy with BAL which was positive for pneumocystis stain. He was treated with TMP-SMX and prednisone and started on ART.

Take Home Points:

An elevated LDH or Beta-D-Glucan in a patient with pulmonary infiltrates should raise suspicion for PJP.

The typical radiographic features of PJP pneumonia is diffuse, bilateral ground glass infiltrates

Diagnosis is made by detecting organism in induced sputum specimen or BAL fluid.

Adjunctive glucocorticoids should be given to patients with room air PaO2 < 70 mmHg and an A-a gradient of >/= 35 mmHg or evidence of hypoxemia.

For further details, or if you wish to review Case 1 for yourself refer to:

Journal of Hospital Medicine, Clinical Care Conundrum, Vol 3, No 1, Jan/Feb 2008


FEVER IN THE RETURNING TRAVELER

Dr. Doan presented an intersting and complex case of fever and malaise in a recently returned traveler. She talked us through some "don't miss" diagnoses, including malaria and enteric fever, and we discussed frameworks for travel-related illness, with a focus on predominant symptoms, geographic location, and incubation periods. Here are some takeaways:

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Below is a sample approach from a NEJM article: "Approach to Fever in the Returning Traveler". You should memorize this algorithm. Just kidding! But do know that resources are available on the CDC website (or in articles like this one), if you find yourself grappling with fever in a returned traveler.

 

Lastly...A Word on Leptospirosis

Reminder-a zoonosis (mammal urine-remember from Step 1?) that causes a nonspecific febrile illness. Dr. Obley dropped some knowledge bombs for us on leptospirosis.

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-Frequently see conjunctival suffusion (redness)

-Weil's disease: leptospirosis complicated by jaundice and renal failure

-Serology: timing of testing matters! antibodies appear in ~5-7 days then can be missed. Need both acute and convalescent samples for diagnosis.    

#OBLEYPEARL

Intermittent Lymphadenopathy! Kikuchi Disease!

Dr. Collins presented a fascinating case of a young woman with 2 months of intermittent cervical lymphadenopathy, intermittent fevers, malaise, and mylagias who was found to have Kikuchi Disease after a lymph node biopsy.

Kikuchi disease is a rare disease that mostly affects women. Dr. Collins's case is a classic presentation. Associated lab findings can include leukopenia with elevated CRP and LDH. It is diagnosed on excisional lymph node biopsy. It is also known as histiocytic necrotizing lymphadenitis based on pathology findings.

Kikuchi disease is benign and self-limited but typically leads to an extensive work up to rule out more sinister diagnoses (lymphoma, TB lymphadenitis, and other infections). Some people treat Kikushi disease with steroids though there is no data on if this improves outcomes.

Interestingly, Kikuchi disease is associated with SLE for unclear reasons. There have been numerous case reports on this association in which SLE followed a prior diagnosis of Kikuchi disease. Some advocate for close follow up for clinical and serologic evidence of developing SLE after a diagnosis of Kikuchi disease.

Intermittent lymphadenopathy should trigger a short differential.

  • T cell lymphoma
    • Illness script: middle aged man with generalized lymphadenopathy
  • Kikuchi Disease
    • Illness script: young previously healthy Asian woman with regional (usually cervical) lymphadenopathy
  • Recurrent infections/immunodeficiency
  • Incompletely treated infectious
derived from AAFP differential for lymphadenopathy and neck mass.    https://www.aafp.org/afp/1998/1015/p1313.html    https://www.aafp.org/afp/2015/0515/p698.html

derived from AAFP differential for lymphadenopathy and neck mass.

https://www.aafp.org/afp/1998/1015/p1313.html

https://www.aafp.org/afp/2015/0515/p698.html

Modern Day Medicine Meets Modern Day Learning!

At noon report, Dr. Logan Jones gave us an update on all the mobile device apps, websites, and podcasts that can be used to optimize medical learning on the go! His presentation was a gold mine for medical knowledge learning! Below are some highlights, but you can refer to his entire presentation here! The presentation includes instructions on how to access through the library via your OHSU account. Thanks, Logan!

Case Based Learning

Honorable Twitter Mentions

Point-of-Care Clinical Decision Support Software

  • Up To Date
  • Dynamed Plus
  • Visual Dx
    • dermatology diagnoses
    • IM differential diagnosis builder
  • uCentral
    • John's Hopkins Antibiotics Guide (free and similary to Sanford's)
    • Harrison's Manual of Medicine ("Baby Harrison's")
    • Prime Journals (follow your fav. journals and access articles on phone)

Miscellaneous Apps

  • ACLS Pathways (iphone only)
  • Supplements/Herbal Resources
    • About Herbs from Memorial Sloan Kettering Cancer Center
    • HerbList from NIH's National Center of Complementary and Intregrative Health, NCCIH
  • Canopy Speak
    • Quick limited medical translator
    • does not replace OHSU certified interpretor services)
  • Visualmed ($4.99)
    • Visual Summary of Landmark Clinical Trials
    • 300 and counting
  • Micromedex
    • trusted and often cited pharmacopaedia
    • Drug reference dosing and interaction are two different apps

Podcasts

 
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Likelihood Ratio Extravaganza

We had a likelihood ratio EXTRAVAGANZA during our noon report last week with Dr. Lewis. Dr. Lewis presented a case of a patient who presented with subacute progressive fatigue, dyspnea on exertion and melena who was found to have a hgb in the 4’s (!) and MCV of 65 on presentation.

We reviewed the JAMA rational clinical exam article on severe upper GI bleed: https://jamanetwork.com/journals/jama/article-abstract/1105075

Likelihood ratio for symptoms of UGIB:

  • Reported history of Melena : +LR 5.1-5.9
  • Melenic stool on exam: +LR 25
  • Serum BUN:Cr ratio >30: +LR 7.5
  • Blood clots in stool: LR 0.05
JL7.17.19.JPG

Dr. Lewis shared another systematic review on diagnostic value of symptoms for colorectal cancer in primary care: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080228/

  • Positive predictive value for symptoms:

    • Rectal bleeding: 8.1%

    • Abdominal pain: 3.3%

    • Anemia: 9.7%

  • Rectal bleeding + weight loss: +LR 1.9

  • Rectal bleeding + change in bowel habits: +LR 1.8

References:

  1. Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed?. JAMA. 2012;307(10):1072-9.

  2. Astin M, Griffin T, Neal RD, Rose P, Hamilton W. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br J Gen Pract. 2011;61(586):e231–e243. doi:10.3399/bjgp11X572427

Hepatopulmonary Syndrome

This week Dr. Kartika presented an interesting case of a patient with Etoh cirrhosis who developed progressive dyspnea on exertion secondary to hepatopulmonary syndrome (HPS).

Triad of:

1. Liver disease

2. Pulmonary vascular dilation

3. Hypoxemia with increased A-a gradient

Liver dysfunction → Release or failure to clear circulating vasodilators such as Nitric Oxide (NO) → inability to constrict pulmonary capillaries leading to relative high perfusion per ventilating unit (i.e. V-Q mismatch).

Mechanism of hypoxemia in HPS

Hepatopulmonary System Image.JPG

Diagnostic Criteria:

HPS diagnostic criteria.JPG

TTE Findings in HPS:

HPS TTE findings.JPG

Take Home Points:

1) Consider HPS in patients with cirrhosis and elevated A-a gradient

2) Diagnosis can be aided by TTE showing R—>L shunt with bubble study after 3 beats

3) TIPS controversial for treatment of HPS and in some circumstances can exacerbate intrapulmonary shunt.

N Engl J Med 2008; 358:2378-2387