Moffitt AM report PEARLS 9/23: cocci, scrofula, monocytosis, and an anatomic approach to weakness

Take-home point on cocci complement fixation: for cocci serologies, complement fixation titers correlate with disease activity and can be used for monitoring (vs immunodiffusion, which is a qualitative test)! Titers >1:16 are concerning for aggressive pulmonary disease OR disseminated disease (bone, joints, skin and meningitis are common). Treatment is often fluconazole or itraconazole, but for very aggressive disease, consider amphotericin. For large lesions causing symptoms, a combined medical/surgical approach is appropriate. Note that African Americans and Filipinos, as well as men and immunocompromised patients, are more prone to disseminated disease. More on cocci here!

Some more learning on scrofula:

  • Scrofula = tuberculous cervical lymphadenitis, which is often unilateral.
  • One of the most common presentations of extrapulmonary TB! Can also be caused by nontuberculous mycobacteria.
  • TB is responsible for up to 42% of peripheral lymphadenopathy in the developing world! In the US, about 20% of pts with TB have extrapulmonary disease (of which 30-40% have lymphadenitis)
  • Often seen in one of 2 situations:
    • reactivation of disease after hematogenous seeding during primary pulmonary TB, or
    • miliary dissemination with prominent LN involvement in the setting of primary pulmonary infection

More misc PEARLS from the case:

  • Approach to weakness: be systematic and think anatomically! Brain (think about the homunulcus!) à spinal cord à neuromuscular junction à peripheral nerve à Check out PEARLS from June here.
  • Short differential for monocytosis (though, keep your differential BROAD!): drug reactions, chronic infections (especially TB and endocarditis), hematologic malignancies, especially hairy cell leukemia
    • A word on CMML (chronic myelomonocytic leukemia): thank you for a PEARL from Rabih that this malignant hematologic disease has pathological features of both myeloproliferative (effective hematopoiesis) AND myelodysplastic diseases (morphologic dysplasia).

Evernote link: https://www.evernote.com/shard/s34/sh/c67f0846-1909-48f8-978b-ee6cf102ce5f/ec73a59940e9704fd6e9baf3eb6e51e4

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