All posts by gsmith003

ZSFG AM Report Pearls 11/27/17: Pulmonary Syndromes in HIV and CT Chest Findings

Thank you to Sarah for presenting an interesting case of a man with HIV with fevers, chills, weight loss, and productive cough as well as a headache. We discussed a broad differential for both pulmonary and CNS infections. This case brought up the need to review some of the classic imaging findings for HIV-associated pulmonary infections.

HIV Pulmonary Syndromes and Radiology Findings:

Information and images comes from radiopaedia.org, which is a great radiology website with lots of great info and images!

Pneumocystis:

CXR:

  • Although up to 90% of chest radiographs in patients with PCP are abnormal, appearances are often non-specific. Between 10-15% of patients with PCP have normal chest radiographs and close to 30% have non-specific or inconclusive findings.
  • Features which are highly suggestive of PCP in patients with CD4 counts below 200/mm3  include:
    • small pneumatocoeles, subpleural blebs
    • a fine reticular interstitial pulmonary pattern
    • there is often a perihilar distribution
  • Pleural effusions are normally not a feature, being seen in less than 5% of cases.

Case courtesy of Dr Behrang Amini , Radiopaedia.org, rID: 35823pneumocystis-pneumonia-8

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 9171

pneumocystis-pneumonia-1.jpg

CT:

High-resolution computed tomography (HRCT) is more sensitive and may be used to exclude PCP in patients with clinical suspicion for PCP but normal or inconclusive chest radiographs.

  • Ground-glass pattern
    • Considered a principal finding
    • Predominantly involving perihilar or mid zones
      • There may be a mid, upper or lower zone predilection depending on whether the patient is on prophylactic aerosolised medication
      • If they are, then the poorly ventilated upper zones are prone to infection, whereas in those who are not, the lower zones are more frequently involved
      • There may be a relative preservation of previously irradiated areas
      • May show some peripheral sparing in a considerable number of patients (~40%)
  • Reticular Opacities or septal thickening may also be present; a crazy paving pattern may, therefore, be seen when both ground-glass opacities and septal thickening are superimposed on one another
  • Pneumatocoeles
    • Varying shape, size, and wall thickness are seen in up to 30% of cases
  • Pleural effusions are rare
  • Lymphadenopathy is uncommon (10%)

 

Case courtesy of Dr Behrang Amini , Radiopaedia.org, rID: 35862

pneumocystis-carinii-pneumonia-3

Case courtesy of Dr Praveen Jha, Radiopaedia.org, rID: 17273

pneumocystis-jirovecicarinii-pneumonia

 

Cryptococcus:

In general, there are several CT patterns that can be seen:

  • Clustered nodular pattern: most prevalent 4
  • Solitary pulmonary nodule or mass with or without cavitation
  • Scattered nodules
  • Peribronchovascular consolidation

The most common CT findings in immunocompetent patients with pulmonary cryptococcosis are pulmonary nodules. The nodules are most often multiple, smaller than 10 mm in diameter, and well-defined with smooth margins. The nodules usually involve less than 10% of the parenchyma and tend to be distributed peripherally in the middle and upper zones. Where there are multiple nodules, they are usually bilateral 2. Associated cavitation may be seen in up to 40% of cases 8. Occasionally, unusual presentation such as large cavities may be seen 13.

Case courtesy of Dr Yale Rosen, Radiopaedia.org, rID: 16218

cryptococcosis-pulmonary-1.jpg

Also check out this website to scrolls through some classic CT scans: 

https://radiopaedia.org/articles/pulmonary-cryptococcosis

 

Tuberculosis

Primary Tuberculosis

  • Wide variability
  • Cavitation is uncommon in primary TB and only seen in 10-30% of cases
  • Often can becomes localized and form a caseating granuloma (tuberculoma)
  • Pleural effusions are more frequent in adults, seen in 30-40% of cases.

Post-Primary Tuberculosis

In the majority of cases, post-primary TB within the lungs develops in either: posterior segments of the upper lobe or superior segments of the lower lobes

  • Patchy consolidation or poorly defined linear and nodular opacities.
  • Far more likely to cavitate than primary infections and are seen in 20-45% of cases.
    • In the vast majority of cases, they develop in the posterior segments of the upper lobes (85%)
    • Hilar nodal enlargement is seen in only approximately a third of cases
    • Lobar consolidation, tuberculoma formation and miliary TB are also recognised patterns of post-primary TB but are less common.

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 8632

pulmonary-tuberculosis-29

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13234

pulmonary-tuberculosis-14

Case courtesy of Dr Natalie Yang, Radiopaedia.org, rID: 9095

pulmonary-tuberculosis-6

Case courtesy of Dr Ruslan Esedov, Radiopaedia.org, rID: 8230

pulmonary-tuberculosis-11.jpg

Evernote:

 

Sources:

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ZSFG AM Report Pearls 11/8/2017: Inpatient Care for Geriatric & Resource for Advance Care Planning

Thank you so much to Julia Janssen for presenting the case of an elderly woman with a history of HFpEF, OSA, pHTN who was admitted for shortness of breath. In talking through this case, we had the opportunity to review the concept of caring for geriatric patients.

Inpatient Care for Geriatric Patients:
  • Remember that geriatric patients are a vulnerable population that likely need additional attention in the hospital
  • Remember that functional status has been repeatedly demonstrated to be a predictor of mortality, 30-day readmission, and readmission over a much longer period of time
Geriatric History and ROS:
Here are a few highlights to consider when taking a medication history:
  • Medications:
    • especially ask about high-risk meds (benzos, opiates, anti-psychotics, anticoagulants, cardiac meds). Consider consulting the Beers list (Click here for PDF)
    • utilize team pharmacist to help with a thorough med rec (look at bottles, call pharmacy, etc)
  • Social History:
    • Social support – loneliness in the elderly is a serious problem that has been linked to worse outcomes
      • Who lives at home with you? Who would you call in case of an emergency?
  • Geriatric ROS: This is somewhat of a comprehensive list, but something to consider
    • ADLs (Eating, Bathing, Dressing, Toileting, Transferring):
    • IADLs (Medications, Laundry, Housecleaning, Telephone Use, Groceries, Bills)
    • Mobility: How many flights of stairs can you go up?
    • Falls: How many falls have you had in the last week, month, year?
    • Depression: Are you feels sad, down, depressed? Have you lost interest in things that used to make you happy?
    • Hearing/Visual Impairment: Do you have any problem with your hearing or vision?
    • DME: Do you have or use any assistive devices?
    • Cognitive Impairment: Have you noticed any changes in your memory? Do you ever find yourself lost or not recognizing people you should know?
    • Driving Status: How many accidents have you been in in the last year?
    • Elder Abuse: Do you ever feel threatened or unsafe at home?
    • Incontinence: Do you have have issues leaking urine or stool?
    • Constipation: Do you ever have any issues with constipation
  • Advanced Directives
    • A MUST, MUST, MUST
    • If nothing has been done, and you want to provide resources for your patient:
    • Additional Resources for Preparing for Advance Care Planning can be found on the following websites:

 

Evernote:

Source:

ZSFG AM Report Pearls 11/6/17: Timing of Injury with Acetaminophen (Tylenol) Overdose

Thank you to Geoff Buckle and Nicole Kim for presenting a case of a patient who presented after an ingestion of acetaminophen (and likely benadryl). Ultimately, we learned about thinking through our toolbox for diagnosis and treatment of a toxic ingestion and questions were raised about the timing of the effects of acetaminophen ingestion.

Acetaminophen Poisoning:
  • Can be caused by both a single, large dose or a slightly higher than recommended dose over time
  • There are 4 stages of overdose
  1. Stage I (0.5-24 hours): Preclinical toxic effects (normal transaminases)
    1. Nausea, vomitnig, diaphoresis, pallor, lethargy, malaise
    2. Typically with normal lab studies
    3. Note that depressed mental status would often be from coingestion (i.e. diphenhydramine, opioids, or ASA)
  2. Stage II (24-72 hours): Hepatic injury (elevated transaminases)
    1. Elevated AST/ALT
    2. May have resolution of symptoms from Stage I
  3. Stage III (72-96 hours): Hepatic failure (hepatic failure with hepatic encephalopathy)
    1. Stage I symptoms may return
    2. Signs of liver failure may occur – jaundice, hepatic encephalopathy, hyperammon
  4. Stage IV (4 days to 2 weeks): Recovery
    1. Symptoms and labs may not normalize for weeks, completed recovery (histologically) can take 3 months
    2. Ongoing chronic hepatic dysfunction is NOT a sequelae of acetaminophen poisoning
Acetaminophen causes damage because 5% of it is metabolized via a pathway that creates a metabolite caused by NAPQI, which causes damage to nucleic acids and proteins. However, this metabolite is detoxified when it interacts with glutathione.
  • N-Acetylcysteine (NAC) restores hepatic glutathione!
    • Found to have 21-28% reduction in mortality for acetaminophen-induced hepatic failure
    • The earlier it is given, the better!
    • Typically used if the serum concentration of acetaminophen falls above the normogram (and some suggest to give if ANY concern for ANY overdose of acetaminophen)

Acetaminophen Normogram

Evernote:

Sources:

  • Heard KJ. (2008). Acetylcysteine for acetaminophen poisoning. NEJM. 359:285-292.

ZSFG AM Report Pearls 10/31/17: Empyema and Chest Tube Problem-Shooting

Thank you to Bennett Caughey for presenting a case of a patient with an empyema whose chest tubes required multiple interventions to adequately drain.

For a refresher on empyema, check out this prior post on Cirrhosis and Empyema. The Evernote is also linked below.

For some basics about chest tubes, check out this prior post including starting wall suction, dealing with air leaks and removing chest tubes.

Managing a Clogged Chest Tube:
Always ask that a provider experienced in chest tubes helps to manage this. You should NOT do this alone as a medicine resident. (i.e. one of your consultants should be helping with management of the chest tube….Pulmonology, Interventional Radiology, General Surgery)
 
Initial Approach:
  • Observe to see if there is tidaling in the collecting device (should see respiratory variation in the fluid level, this indicated functioning)
  • Look for kink in the tubing outside the patient, and get a CXR to look for a kink in the tubing inside the patient
  • Visually inspect the tubing for a clog of debris or blood clot
Manual Maneuvers:
  • “Stripping the Chest Tube” – only perform if CERTAIN that the tube is in the correct position and not next to mediastinal structures. Essentially pinch the tube at insertion and pull toward the drainage system. (Recommend using some lubricant between your fingers and the tube).
  • “Sterile-Condition Maneuvers”
    • Twisting the tube 360 degrees
    • Pull the tube out 1-2cm
    • Pass a sterile endotracheal tube suction
    • Inject small volume of sterile saline with povidone-iodine
    • Wire passage
Fibrinolytic Therapy:
  • Used to lyse loculated pleural fluid collections, most commonly complex parapneumonic effusions or empyema.
  • Typical use recombinant tissue-type plasminogen activator (r-tPA)
    • Typically 2-6mg dose diluted in 25-100mL sterile saline, instilled directly into chest tube
    • Solution sits in chest tube 1-2 hours, while chest tube clamped
  • DNase is another substance to break up clogs has also been used
  • In a trial of 193 patients with empyema in the UK, compared DNase alone, tPA alone, and combination of DNase + tPA:
    • There was a significant increase in the amount of pleural fluid drainage with DNase + tPA compared to placebo
    • There was no difference between DNase alone or tPA alone compared to placebo
    • Hospital stays were also shorter on average in the DNase-tPA group, but no difference in DNase or tPA alone

 

Evernote:

  • Empyema: https://www.evernote.com/shard/s509/sh/62703430-862c-4e6d-bbf1-686d9f266408/e7c375ba2db7b08029ace851265ddaef
  • Chest Tube Management: https://www.evernote.com/shard/s509/sh/1bfb2428-bad5-41be-b80a-cba7d98ff2f1/ff0900ea825217a7a423304291bb3804

Sources:

  • Hogg JR et al. (2011). Tube thoracostomy: A review for the interventional radiologist. Seminars in Interventional Radiology. 28(1): 39-47.
  • Rahman NM et al. (2011). Intrapleural use of tissue plasminogen activator and DNase in pleural infection. NEJM. 365(6):518-526

ZSFG AM Report Pearls 10/11/17: Perioperative Management of Anticoagulation

Thank you to Dr. Dan Reiss for presenting the case of a patient on anticoagulation for atrial flutter and a left atrial thrombus who was scheduled to undergo a planned surgical procedure. We discussed perioperative anticoagulation guidelines and considerations.

Peri-Operative Management of Anticoagulation:
Broad Framework:
  • Assess bleeding risk
  • Assess thrombotic risk
  • Consider:
    • Patient Factors
    • Procedure Factors
  • Use a resource of Guidelines to help make your decision (as there are lots of caveats and factors to remember)
Assessing Thrombotic Risk
  • High Risk
    • CHADS2 5-6
    • TIA/CVA < 3 months
    • Afib w/ stoke/TIA w/in 12 months
    • Acute VTE or arterial embolism within 3 months
    • Mechanical aortic valve prosthesis and history of CVA/TIA/AFIB/low EF
    • Mechanical mitral valve prosthesis or 2 or more prosthetic heart valves
    • Caged ball or tilting disk aortic valve prosthesis
    • Rheumatic mitral valve disease
    • History of recurrent VTE while on anticoagulation or during brief interruption
    • Severe thrombophilia (deficiency of protein C, protein S or antithrombin, antiphospholipid antibodies, or multiple thrombophilic abnormalities)
    • VTE within 6 months in setting of cancer with a very high thrombotic risk
  • Moderate Risk
    • CHADS2 3-4
    • Non-valvular atrial fibrillation with history of stroke/TIA > 12 months prior
    • Unprovoked VTE within the past 3 to 12 months
    • Cancer-associated VTE within 6 months (if cancer is high TE risk, may consider bridge)*
    • Mechanical aortic valve prosthesis with one or more of the following: hypertension, diabetes, age >75 yr
    • Non-severe thrombophilia (heterozygous factor V Leiden, PT20210 mutation)
  • Low Risk
    • CHADS2 0-2, no prior TIA/CVA
    • Non-valvular atrial fibrillation without history of stroke/TIA  VTE occurring >12 months ago
    • Mechanical aortic valve prosthesis without atrial fibrillation (AFIB) or other major risk factors for stroke (low EF, hypercoag state)
CHEST Guidelines for Thrombotic Risk
Assessing Risk of Bleeding
  • History of bleeding
  • Talk to surgeon to assess risk of procedure, surgeon’s comfort
Peri-Operative Management of Anti-Platelets:
Single Agent Antiplatelet (i.e. Aspirin only for primary or secondary prevention)
  • Almost always OK to stop if asked by surgeon
  • Many surgeons and surgical procedures are probably OK to complete while on ASA
 
Dual Antiplatelet Therapy
  • Typically should NOT be interrupted for 6 months if taking for a coronary stent
    • i.e. should delay surgery if cannot be done on dual antiplatelet
    • Less data available able recommendation if on dual antiplatelet for other reasons
  • Talk with surgeon about bleeding risks

Resources:

Evernote:

  • Anticoag in Peri-Operative: https://www.evernote.com/shard/s509/sh/5ebffea1-5109-4c43-8a1d-cdfa489acd4c/9b9148b43647e57d3ba0f9cd1f0ab8e0

ZSFG AM Report Pearls 10/10/17: HIV Hx Taking and PCP PPx Pearls

Thank you to Maxime for presenting an interesting case of a patient with poorly-controlled HIV with a low CD4 count who presented with SOB and AMS of 2 days duration. We discussed the challenges of framing severely immunosuppressed patients who may have multiple issues. We also captured a few pearls from Susa Coffey about HIV care.

Key Components of an HIV-History:

  • **Last CD4 & Viral Load – helpful esp within the last 6 months
    • Consider new CD4 count if >6 months since last, recognizing CD4 altered in acute illness
  • **Use of ARVs – especially noting ability to adhere to regimen
  • Hx of Opportunistic Infections – may raise your suspicion for particular etiologies
  • CD4 Nadir – gives you  sense of where their CD4 may be if they have not been able to adhere to an ARV regimen and may help raise suspicion for OIs

 

PCP/PJP Pneumocystis Prophylaxis:

Indications:
  • CD4 <200
  • Consider in CD4% <14%
  • Consider in CD4 200-250 if ARVs are going to be delayed
  • NOTE: Not needed if already on PPx or Toxoplasmosis with pyrimethamine-sulfadiazine
Prophylaxis Regimens:
  • TMP-SMX (Bactrim) 1 DS tablet daily (although 1 single-strength also effective)
    • Note: should re-challenge with Bactrim even if they have a mild reaction (as long as not life threatening reaction)
    • Only consider alternative therapy if life-threatening reaction like Stevens-Johnson Syndrome pr TEN
  • Dapsone
  • Dapsone + Pyrimethamine plus leucovorin (especially if need toxoplasmosis ppx needed)

 

Sources:

  • CDC Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/321/pcp

Evernote:

  • PCP Prophylaxis: https://www.evernote.com/shard/s509/sh/a9ef840b-2b69-4c83-af7f-b39da84fa5ce/2c7cbba4a6c0e67f31a1c5f5b4202988

ZSFG AM Report Pearls 10/4/2017: Sarcoidosis

Thank you to our team at ZSFG for presenting the case of a patient with sarcoidosis who presented with a history of falls, weight loss, and shortness of breath that brought up some questions about the basics of sarcoidosis. Check out the post below about some basics on sarcoidosis.

SARCOIDOSIS:
Pathophysiology:
  • Fundamental abnormality is formation and accumulation of granulomas (compact, centrally organized collections of macrophages and epithelioid cells encircled by lymphocytes).
  • About 20-25% of patients will develop pulmonary fibrosis due to matrix metalloproteinases
Clinical Features:
  • Often first seen on CXR for another reason
  • Fatigue, night sweats, and weight loss are common
  • Lofgren’s Syndrome: arthritis, erythema nodosum, bilateral hilar adenopathy
  • 2/3 of patients have remission within a decade after diagnosis with few or no consequences
  • 1/3 of patients have unrelenting disease
Diagnosis:
  • Unless presenting with classic Lofgren’s syndrome, typically need to have a biopsy specimen demonstrating noncaseating epithelioid-cell granulomas in the absence of organisms or particles.
    • Should biopsy from easiest access point (skin, peripheral lymph nodes, lacrima glands)
    • Sometimes, you may still need a bronchoscopy to get lung tissues
  • Need to rule out other infections (i.e. TB, bacterial cultures)
  • There is no value to checking a serum ACE level:
Organ Involvement:
  • Pulmonary: can present with a restrictive spirometry pattern (underlying fibrosis), pulmonary HTN
  • Cutaneous: can be disfiguring can be macules, papules, plaques and erythema nodosum
  • Liver/Spleen: typically clinically silent liver problems, but can include liver failure
  • Neurologic: involved in 25% of patients on autopsy, 10% clinically. MRI with gadolinium is useful for detecting involvement. Complications common to uncommon:
    • Cranial-nerve palsies
    • Headache
    • Ataxia
    • Cognitive dysfunction
    • Weakness
    • Seizures
  • Optho: anterior uveitis most common manifestation
  • Cardiac: Typically cardiomyopathy, can also present with tachy- or brady-arrhythmias. Diagnosis helped with MRI with gad and PET scanning to aid in dx (biopsy is limited b/c of the patchy nature of disease).
  • Renal: Can have hypercaliuria and renal calculi
  • Bone: Bony lesions can be seen throughout the skeleton, often confused
Treatment:
Treatment for Sarcoid

Sources:

  • Iannuzzi MC et al. (2007). Medical progress – Sarcoidosis. NEJM 347:2153-2165.

Evernote:

  • Sarcoidosis: https://www.evernote.com/shard/s509/sh/ff61b59b-6f75-456d-b99d-972fa8a4c790/e83ad7376c5ec6e2f8d33d64c9528ddc