Day #295 - Tuberculosis and Immune Reconstitiution

We discussed a case of pulmonary and extrapulmonary tuberculosis which presented on TNF-alpha antagonist therapy.

Addendum: TB Immune Reconstitution Reviewed Recently here.

We also discussed paradoxical worsening of TB post-discontinuation of immunosuppression. The case report I was talking about is available here.

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.