Day #293 - Advanced ETOH Cirrhosis

Today we discussed

1. ETOH dependency and withdrawl
2. Alcohol and tylenol co-ingestion
3. Cirrhosis, and the management of cirrhotic complication

Day #292 - Meningoencephalitis

Today we discussed a few issues:

1. The developing influenza outbreak (see previous blogs on influenza). A review of the neurologic manifestations of influenza infection is available here.
   
2. A case of meningoencephalitis (see TWH blog), presumably due to mumps (though I have my reservations as the parotid enlargement classically predates the encephalitis and the IgM is still pending!)
3. TB Meningitis was discussed given the epidemiology.
   

Day #289 - Hypernatremia

Today we talked about a patient with decreased level of consciousness from hypernatremia.

This a great review of the topic.

The key in management is to provide free water at a rate that allows the serum sodium to decrease 10mmol/L/24h. This is usually accomplished after treating any severe ECF volume contraction with normal saline.

Day #288 - Fulminant Hepatitis from Hepatitis B

Today we discussed a case of a patient with chronic hepatitis B who presented with massive elevations of his liver enzymes. The cause was felt to be a flare of his underlying hepatitis B.

Day #287 - Massive Splenomegaly

Today we heard about a patient with massive splenomegaly who presented with symptoms anorexia and weight loss.

We discussed the physical diagnosis of splenomegaly. We also talked about differentiating the spleen from an enlarged kidney or stomach based.

Spleen

• Has notch
• Cannot palpate above
• Descends with inspiration
• Cannot ballot
• Splenic rub

Kidney

• No notch
• Can ballot
• May be able to palpate above
• No change with inspiration

Stomach

• No notch
• Cannot ballot
• Can not palpate above
  
• Succession splash
  

We then discussed the differential diagnosis for massive splenomegaly (8cm below costal margin or greater than 1kg) which includes:

• CML, CLL, Hairy Cell Leukemia, and other lymphomas
• Myelofibrosis (less commonly PRV)
• Gaucher's disease (or rarely sarcoidosis)
• Autoimmune Haemolytic Anemia
• Kala-Azar

Remember, the spleen can be enlarged by three mechanisms:

1. Hypertrophy or hyperplasia related to increased splenic function (i.e. thalasemia, infection, autoimmune disease)
2. Congestion due to portal hypertension
3. Infiltration (i.e. lymphomas, leukemias, extramedulary haematopoesis, amyloid)

We finally ended up talking about making the diagnosis in this case, which is likely lymphoma.

Day #280 - Anion Gap Metabolic Acidosis in an Alcoholic

Today was great!

We talked about the approach to acute confusion.

Then we talked about alcohol withdrawl and the treatment thereof. An approach that seems "easy" to remember is to use CIWA-A hourly giving 15mg for CIWA-A 8 to 15 and 30mg for scores above 15. Diazepam or lorazepam can be substituted. Disorientation and hallucinosis can be treated with small doses of haloperidol (i.e. 2.5-5mg)

Then we talked about the differential diagnosis of anion gap metabolic acidosis and the fact that the osmolar gap can sometimes be normal in toxic alcohol poisoning.

Then we talked about the management of HONK/DKA.

Day #279 - Cirrhosis and Possible Myxedema Coma

The patient (not the man in the picture!!) today had alcohol induced cirrhosis -- cirrhosis, its complications, and treatment thereof previously blogged (here, here, and here) with hepatic encephalopathy, massive ascites, and jaundice and possible hepatorenal syndrome.

We also later learned that the patient initially underreported their alcohol consumption. I couldn't find any literature on this in patients with cirrhosis; however, in my experience this is common.

The red-herring in this case was the anorexia and hoarse voice with cough which was supicious for malignancy -- however, we later found out that the patient was also severly hypothyroid which may have explained the hoarse voice -- and the anorexia could be explained by the severe liver disease.

The mental status may have also been depressed due to superimposed myxedema coma and it was important to recognize this.

Day #278 - Cavitary Lung Lesion

Today we heard the case of a young man with a history of constitutional symptoms (sweats, weight loss) in association with a non-productive cough and a cavitary right upper lobe infiltrate.

I have previously blogged about the differential of cavitary lung lesions

Based on the presentation I favor an infectious etiology, most likely tuberculosis. The absence of AFB on the bronchoscopy does *not* mean this isn't tuberculosis.

This study of 230 cases of culture positive pulmonary tuberculosis showed that the BAL AFB stain was only positive in 48/95 patients without spontaneous sputum production. In this study, the sensitivity of BAL AFB stain was better, but still only 70%.

The take home message is that a negative smear does not exclude TB in a compatible case. Repeat samples are sometimes indicated and awaiting the final culture is also required. In this case I would add induced sputum daily in the AM for three days to maximize my chances of making the diagnosis.

This article reviews the various radiographic manifestations of pulmonary tuberculosis.

Treatment of Pulmonary TB (see Canadian Tuberculosis Standards):
Initial:

• Isoniazid (INH) +/- Vitamin B6
  
• Rifampin (RIF)
  
• Pyrazinamide (PZA)
  
• Ethambutol (ETH)
  

If demonstrated susceptible to INH/RIF/PZA:

• Can stop ETH immediately
  
• Continue INH/RIF/PZA until 2 months then stop PZA
• Continue INF/RIF 4 months to complete 6 total months
  

Day #273 - Autoimmune Haemolytic Anemia (AIHA)

Great case of haemolytic anemia presenting as shortness of breath. I have previously blogged about AIHA and linked to good articles here. The approach to anemia is discussed in this blog, and the approach to microangiopathic haemolytic anemia (and TTP).

We also discussed the approach to dyspnea as a presenting illness which is easily remembered by the pneumonic FIT-RCMP


Fitness (i.e. out of shape)
R - Respiratory causes
C - Cardiac Causes
M - Metabolic (anemia and hyperthyroidism)
P - Psychological

... And I stand corrected -- a pulsus pardoxus of 10mmHg is felt to be signficant. Less than 10mmhg is highly sensitive for ruling out (LR -ve of 0.03) , more than 12 is more specific for ruling in (LR +ve 5.9)

Scenario Rounds - Severe Asthma and Severe Hypothermia

A good review of severe asthma is available here. The ACLS guidelines are available here.

The ACLS guidelines for the hypothermic patient.

Day #267 - Seizure

Today we heard a very complicated case of a man with an extensive cardiac and vascular history who presented with decreased level of consciouness and paresis which was felt to be due to a seizure (Todd's paresis)

The underlying cause for the seizure was presumed to be multiple old and subacute infarcts, the etiology of which was unclear -- but suspicious for embolism given his recent large territory myocardial infarction.

There is a good NEJM review of the initial treatment of epilepsy here. Another good review on the use of anti-seizure medication in adults and the elderly is available here. Choice of therapy depends on a number of issues:

1. Efficacy of medication for clinical scenario (i.e. partial complex vs. generalized)
2. Side effect profile and patient history
3. Drug-Drug Interactions
4. Cost or availability
5. Familiarity of prescriber

Most patients I see have been started on phenytoin, which is an old drug with poor pharmacokinetics and many drug-drug interactions. This drug is chosen because of low cost, familiarity, availability of IV formula. It can be effective. The article cited above would suggest that we have alternative options.

Though not discussed today, I have previously blogged about status epilepticus here.

One astute participant mentioned driving. The CMA has guidelines on medical fitness to drive which you can access for free here. The medical condition report form is available here.

Day #266 - Febrile Neutropenia

Today we discussed a case of a patient with multiple immunological deficiencies (a review of primary immunodeficiencies is available here)

Multiple myeloma with dysgammaglobulinemia predisposing to infections with encapsulated organisms like streptococcus pneumoniae and other bacterial infections like staphylococci.

High dose prednisone leading to relative deficiencies with cell mediated immunity predisposing to intracellular organisms (i.e. salmonella, listeria), mycobacterial, and fungal infections.

TNF alpha antagonist leading to further risk of fungal and mycobacterial infections

And drug induced febrile neutropenia predisposing to infection with bacteria including pseudomonas as well as fungi such as candida species, aspergillus, and other moulds.

The 2002 (under revision) IDSA guidelines for the management of febrile neutropenia are available here.

When initially seeing the febrile neutropenic patient, the goals (in general) are to:

1. Stablize and rescucitate as appropriate
2. Identify any specific focus of infection on history and physical exam
   
   • Pay attention in particular to sinuses and dental sources, mucositis, new murmurs, skin foci including central line sites and tunnels, evidence of pneumonia, evidence of intrabdominal focus, peri-rectal exam (no DRE)
   • CXR for all cases. Sinus, CT thorax, abdominal, other imaging as clinically indicated.
     
3. Obtain cultures from all sites including two sets of blood cultures and cultures from any indwelling intravenous lines.
   
4. Initiate broad spectrum antibiotic therapy to cover for usual pathogens implicated in febrile neutropenia adjusting/broadening to include identifiable focus
   
   • In general an antipseudomonal beta-lactam combined with an aminoglycoside is a standard regimen with the addition of VANCOMYCIN in patients with indwelling intravenous catheters, risk for MRSA, or who come in pre-treated with quinolone prophylaxis
5. Tailor antibiotics to culture results but remain broad-spectrum while neutropenic
   
   • i.e. if no gram positive identified can consider stopping VANCOMYCIN at 72h
     
   • if no pseudomonas or gram negative identified at 72h can consider stopping aminoglycoside and continuing the beta-lactam
     

Day #265 Hypertensive Emergency

Today we discussed a case of a patient from a marginalized social status with severe hypertension, decreased level of consciousness and seizure.

The issue of possible cocaine intoxication came up. A review of the cardiovascular consequences of cocaine use is presented here.

The management of hypertensive emergencies also was discussed. In general, with the exception of aortic dissection, the goal is to lower the blood pressure by ~25% of the mean arterial pressure in minutes to hours, and then achieve control of the blood pressure over the next days.

Options include intravenous labetolol (caution in catecholamine excess states like cocaine and pheochromocytoma) and nitrates like nitroglycerin (NB tachyphalaxis, not 1st line in aortic dissection) or nitroprusside (NB cyanide accumulation if renal failure or greater than 24h use, not 1st in aortic dissection).