Day #161 - Autoimmune Haemolytic Anemia

The last morning report @ TGH. I move to MSH in January.

Today we heard a case of auto-immune haemolytic anemia presenting as symptomatic anemia. The patient may have had a prodromal illness.

This is a great article on AIHA. This one is good too.

In reading these something interesting became clear -- in what appears to be AIHA with a negative DAT there are a few possibilities.

• Subthreshold antibody (below the level of detection with DAT) -- this may be mitigated using a different method of DAT
  
• hereditary spherocytosis
• clostridial sepsis
  
• Two interesting ones include wilson's disease and Zieve's syndrome.

NB: AIHA with ITP (either together or sequentially) = Evan's Syndrome

Day #160 - Acute Hepatitis

I have previously blogged about acute hepatitis, and have linked to a great article on acetaminophen overdose. Please see here.

Day #159 - Fever of Unknown Origin - The Return

Due to fun rounds time constraints -- will point you to my previous blogs on FUO -- here.

Day #158 - TIA (and Stroke)

Today we talked about a case of a patient with a presumed cardioembolic (atrial fibrillation mediated) TIA and evidence of old parieto-occipital stroke.

We discussed the use of anticoagulants such as warfarin in atrial fibrillation and the CHADS2 score. This patient was "warfarin allergic". Often this is an allergy to the dye in the tablets, and one can use dye free tablets.

In these patients you can also consider nicoumalone (Sintrom) which is another oral vitamin K antagonist that is structurally different (and twice as potent). An alternative (though I am unsure of its availability in Canada) is Anisindione.

This is a great review article on the use of oral vitamin K antagonists.

In acute stroke bridging with LMWH or UFH while waiting for a therapeutic INR is usually not indicated

Note that it probably would be indicated in patients with prosthetic valves who have had embolic strokes.

We also discussed TIAs and the ABCD2 score for prognosticating the risk of stroke in TIA.

Day #155 - Complicated anemia

Today we discussed a medically complex patient presenting with subacute anemia. We discussed an approach to anemia with reticulocytopenia. I have blogged about anemia a few times before (here and here (macrocytic anemia)).

This article discusses the issue of pure red cell aplasia in the context of synthetic EPO.

This Toronto study talks about the use of supplemental iron in dialysis patients.

Day #154 - Severe hypothyroidism (Myxedema Coma)

Today we discussed a case of severe hypothyroidism presenting with impaired cognition, bradycardia and hypothermia.

We discussed the treatment of severe hypothyroidism/myxedema coma:

• Supportive care
• IV levothyroxine 200-500mcg then 100mcg q24h until improving then oral 1.6mcg/kg
  
• After obtaining ACTH, cortisol levels, strongly consider stress dose steroids until concommitant adrenal insufficiency is excluded
• Look for precipitant (infection, MI, other)
• Empiric antibiotics for possible sepsis while awaiting cultures
  

This article discusses the polyglandular autoimmune syndromes.

Day #153 - Pneumocystis (PCP) Redux

Today we heard a case of PCP pneumonia with a classic presentation. For those of you who will end up doing medical education -- you should start saving up cases during your residency that you can use as exemplars of diagnoses, management, or approaches -- especially if they have key teaching points or interesting imaging. This will also help you for when you are suddenly called upon to provide impromptu teaching.

I have previously blogged in detail about PCP here. This blog links to a number of other blogs and articles that are also useful.

Day #152 - Iron Defieicency Anemia and Cirrhosis

Today we talked about an interesting case of a patient with cirrhosis (presumably alcohol and hepatitis C related) who presented with ascites, confusion, and anemia.

Cirrhosis (including approach to ascites and SBP) previously blogged here and here
Upper GI bleeding previously blogged here, here, and here.

Anemia previously blogged here and here (macrocytic anemia).

NB: One of the key teaching points in this case is that "iron deficiency anemia" is a not a diagnosis until you understand *why* the patient has iron deficiency. Are they not eating iron, not absorbing iron, losing iron (bleeding or losing in the urine in intravascular haemolysis)?

In people with no evidence of occult blood loss in the GI tract and no other evident losses, you should consider the diagnosis of celiac disease.

Day# 146 - Two cases

We talked about a case of stroke in a young patient. An approach to stroke in a young patient is outlined briefly here.

The case turned out to be meningovascular syphilis.

Here is an interesting article on the history of syphilis and another which talks about whether or not Shakespeare himself was infected.

The second case was that of massive liver enzyme elevation with synthetic dysfunction. I have previously blogged about hepatitis here.

Day #145 - Pyogenic Liver Abscess

Today we heard about a great case of pyogenic liver abscess. I wanted to clarify a few points of discussion.

Pathogenesis (most common in blue):

• Ascention of pathogens up biliary tree
• Ascention of pathogens through portal circulation. Often in the context of an intraabdominal nidus of infection like diverticulitis. May be in context of septic portal thrombophlebitis
• Cyptogenic
• Direct innoculation from trauma or iatrogenic
• Hematogenous spread from systemic infection
• Direct spread from gallbladder infection

Pathogens

• Gpc - strep milleri and other alpha haemolytic strep.
• Gnr - ecoli and klebsiella. Anaerobes (which often won't grow in culture)
  

• Amoebic liver abscess
• Hydadid cyst disease (echinococcus)

Treatment:

Pyogenic - use emperic coverage that will cover most pathogens above - I.e. Pip/tazo or ceftriaxone/metronidazole. Narrow spectrum to culture results not forgetting anaerobes

Drainage - either IR or surgical -- "Never let the sun set on undrained pus"

Amoebic - metronidazole 750po TID x 10 days followed by luminocidal agent

Hydadid - Specialized surgical care.

Day # 144 - Pulmonary Hypertension

Today we discussed a case of severe pulmonary hypertension presenting with shortness of breath and right heart failure.

There is a great review article on pulmonary hypertension here.

We initially discussed the physical exam findings in pulmonary hypertension:

JVP - Often elevated, may have CV waves if has tricuspid regurgitation, may have kussmaul's sign or abnormal abdominojugular reflux if RV failure

Palpation - RV lift/heave, epigastric heave, palpable second heart sound (P2), palpable RV S3 or S4, palpable thrill of TR

Auscultation - Loud second heart sound. May be widely split. Murmur of TR (LLSB radiating to epigastrium, apex or LUSB, holosystolic blowing murmur with respiratory increase (Carvallo's sign)). Right sided S3/S4

Abdominal Exam:

Ascites, pulsitile liver

Peripheral Exam:
Edema

We then discussed etiologies:

We then discussed the treatment options for pulmonary hypertension. This depends on the cause.

For group II, III, IV you need to try and treat the underlying problem (i.e. LV failure or MS/MR, chronic hypoxemia, sleep apnea)

The best evidence for treatment is in group I. But they are using these drugs for more and more conditions.

The options are:

Calcium channel blockers (don't really work)

Consider anticoagulation

• Phosphodiesterase inhibitors (like sildenafil)
• Prostaglandin infusion (like Flolan)
• Endothelin Receptor inhibitors (like Bosentan)