This was a case of a man from an endemic country with an encephalopathy of several weeks duration and a lumbar puncture with a lymphocytic pleocytosis, elevated protein, low glucose and no organisms on the LP. Viral PCR was also negative as were fungal studies. The presumed diagnosis on clinical grounds was TB meningitis.
A modern era review article including a discussion on the role of nuclear antigen testing is here.
The role of adjunctive dexamethasone in TB meningitis is described in an article from NEJM here.
There is a *great* free resource called the Canadian Tuberculosis Standards available here. This reference text provides a plethora of useful information on tuberculosis and would be a worthy addition to anyone's collection.
Wednesday, January 28, 2009
Monday, January 26, 2009
Day #200 - Hemoptysis
Today we discussed a case of a patient with hemoptysis x months with associated weight loss. One of the episodes sounded like "massive hemoptysis"
I have previously discussed hemoptysis here.
We discussed the importance of differentiating hemoptysis from hematemesis and epistaxis. I have previously blogged about upper GI bleeding a few times (linked from here)
In the end, we had a chest xray showing middle lobe collapse with a CT scan showing two probably tumours within the lung. The University of Auckland has an interesting site looking at the anatomy as viewed by CT thorax.
We finished by discussing the staging of lung cancer.
I have previously discussed hemoptysis here.
We discussed the importance of differentiating hemoptysis from hematemesis and epistaxis. I have previously blogged about upper GI bleeding a few times (linked from here)
In the end, we had a chest xray showing middle lobe collapse with a CT scan showing two probably tumours within the lung. The University of Auckland has an interesting site looking at the anatomy as viewed by CT thorax.
We finished by discussing the staging of lung cancer.
Thursday, January 22, 2009
Day #196 - Confusion
The blogs this month are short because I am on clinical service...
We've previously discussed an approach to acute confusion here.
Today we talked about a 83 year old woman with underlying cognitive impairment with acute confusion. When I hear this stem, I think "what have we, as doctors, done iatrogenically to cause this" because this is probably one of the most common causes.
In this case the patient had a metabolic acidosis, with a wide anion gap. The differential diagnosis includes "MUDPILES". In this case, it was probably a combination of uremia/renal failure and starvation ketoacidosis.
M - methanol poisoning
U - uremia
D - diabetic ketoacidosis/alcoholic ketoacidosis/starvation ketoacidosis
P - paraldehyde
I - iron/INH overdose
L - lactic acidosis: type A (tissue hypoperfusion or ischemia) type B (failure of liver to clear lactate (i.e. liver failure, metformin toxicity, beri-beri)
E - ethylene glycol
S - salicilates
One can calculate the osmolar gap to look for osmotically active compounds (such as the toxic alcohols).
Osmolar gap = measured osmoles - [2xNa + glucose + urea]
normal <10>
Remember, that sometimes in later stage toxic alcohol poisoning the osmolar gap may be normal despite significant toxicity. See this case.
We've previously discussed an approach to acute confusion here.
Today we talked about a 83 year old woman with underlying cognitive impairment with acute confusion. When I hear this stem, I think "what have we, as doctors, done iatrogenically to cause this" because this is probably one of the most common causes.
In this case the patient had a metabolic acidosis, with a wide anion gap. The differential diagnosis includes "MUDPILES". In this case, it was probably a combination of uremia/renal failure and starvation ketoacidosis.
M - methanol poisoning
U - uremia
D - diabetic ketoacidosis/alcoholic ketoacidosis/starvation ketoacidosis
P - paraldehyde
I - iron/INH overdose
L - lactic acidosis: type A (tissue hypoperfusion or ischemia) type B (failure of liver to clear lactate (i.e. liver failure, metformin toxicity, beri-beri)
E - ethylene glycol
S - salicilates
One can calculate the osmolar gap to look for osmotically active compounds (such as the toxic alcohols).
Osmolar gap = measured osmoles - [2xNa + glucose + urea]
normal <10>
Remember, that sometimes in later stage toxic alcohol poisoning the osmolar gap may be normal despite significant toxicity. See this case.
Tuesday, January 20, 2009
Day #194 - Stroke in the Young
Monday, January 19, 2009
Day # 193 - Hyponatremia
Tuesday, January 13, 2009
Day #187 - Intracranial Hemmorhage
Today we discussed a case of intracranial hemorrhage presenting as a stroke like syndrome with confusion, aphasia and neglect.
I have previously blogged about acute confusion and aphasia here.
Intracerebral Hemorrhage:
The key aspects to management of ICH include:
I have previously blogged about acute confusion and aphasia here.
Intracerebral Hemorrhage:
- Second most common cause of stroke syndrome
- Mortality -- ICH Score
- GCS 3-4 (=2 pts) 5-12 (=1 pt)
- ICH greater than 30cm2 = 1 pt
- Intraventricular extension (spills into ventricles) = 1 pt
- Infratentorial =1
- Age greater than 80 =1
The key aspects to management of ICH include:
- Reverse coagulopathies
- Reduce blood pressure (goal generally 160-180 systolic) to minimize further bleeding and maximize cerebral perfusion
- Stop ASA/plavix -- can consider restarting day 10
- Reverse anticoagulation from warfarin -- Prothrombin Complex Concentrate and Vitamin K or FFP
- Can consider restarting @ 2 weeks (tight monitoring) and usually only for hard indications like mechanical heart valves.
- Can consider restarting @ 2 weeks (tight monitoring) and usually only for hard indications like mechanical heart valves.
- Reverse heparin -- protamine sulfate
- Initial excitement about rFVIIa -- now in question.
- Head of bed at 30 degrees
- Analgesia
- Mannitol, surgery if profound increase
- Greater than 200 systolic or MAP 150 -- reduce to 160-180
- 160-180 and increased ICP -- consider ICP monitoring and aim for CPP (MAP-ICP) of 60-80
- 160-180 no increased ICP -- goal 160 MAP 110
Day #186 - PCP/HIV
I wasn't there (post-call) but I've blogged about this before and I encourage you to read that here.
Friday, January 9, 2009
Day #183 - Severe Influenza Redux
Previously presented this 'classic' case here.
Dr. Allison McGeer, the director of infection control and an infectious diseases physician here at MSH has recently published an article discussing the use of empiric influenza treatment in hospitalized patients here.
You can look up the current level of influenza across Canada here.
Dr. Allison McGeer, the director of infection control and an infectious diseases physician here at MSH has recently published an article discussing the use of empiric influenza treatment in hospitalized patients here.
You can look up the current level of influenza across Canada here.
Thursday, January 8, 2009
Day #182 - Tylenol Overdose
I have previously blogged about hepatitis and tylenol overdose here and here.
The article the discussant mentioned on alcohol and tylenol overdose is available here. There is a newer publication that looks retrospectively at 20 years of ingestion data and adjusts the classic Rumack-Matthew nomogram for chronic alcohol use (without simultaneous co-ingestion).
A similar study proposes to predict the risk of hepatotoxicity using a combination of the tylenol level, the time since ingestion, and the time N-AC is started.
There is some evidence that simultaneous co-ingestion may be protective. This effect, and the effect of alcohol are quantified in the table here (based on the above nomogram)
A good review article on alcoholic hepatitis is available here.
Other groups have suggested that the glascow alcoholic hepatitis score >=9 is more useful in predicting benefit from corticosteroids than the DF.
The article the discussant mentioned on alcohol and tylenol overdose is available here. There is a newer publication that looks retrospectively at 20 years of ingestion data and adjusts the classic Rumack-Matthew nomogram for chronic alcohol use (without simultaneous co-ingestion).
A similar study proposes to predict the risk of hepatotoxicity using a combination of the tylenol level, the time since ingestion, and the time N-AC is started.
There is some evidence that simultaneous co-ingestion may be protective. This effect, and the effect of alcohol are quantified in the table here (based on the above nomogram)
A good review article on alcoholic hepatitis is available here.
Other groups have suggested that the glascow alcoholic hepatitis score >=9 is more useful in predicting benefit from corticosteroids than the DF.
Wednesday, January 7, 2009
Day #181 - Pulmonary Embolism
Today was a case of pulmonary embolism in a patient with advanced malignancy.
We didn't really talk about PE -- but the discussant talked about very relevant issues including end of life care, diagnostic reasoning and clinical decision making.
For your information, I have previously blogged about DVT/PE here and thrombophilia here.
Addendum: NEJM article from Jan 2009 on PE.
We didn't really talk about PE -- but the discussant talked about very relevant issues including end of life care, diagnostic reasoning and clinical decision making.
For your information, I have previously blogged about DVT/PE here and thrombophilia here.
Addendum: NEJM article from Jan 2009 on PE.
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