All posts by gsmith003

ZSFG AM Report Pearls 3/6/18: Let’s Get It Ulceratin’; While You’re Waiting, So Just Poop for Me

Thank you to Lauren Lederle for presenting an interesting case of a patient who has had a prolonged hospital course with fluctuating course of ileus. There were so many great learning pearls during this report, we will focus on 3 separate things cause they were too good: 1. Strep Bovis, 2. Ulcerating GI lesions in HIV, and 3. CMV testing


Strep Bovis:
  • Associated with GI malignancy (especially colon cancer)
  • Thought of as coming from a GI source
  • Can cause endocarditis
  • Also called Strep gallolyticus


CMV Diagnostics:

  • Which test to send for CMV work-up depends on the immune status of the patient
Immunocompromised (Non-HIV):
  • CMV igG (this can help risk stratify)
  • CMV PCR from serum
Immunocompromised (HIV):
  • Serology is not helpful as most of these patients with be positive CMV IgG
  • PCR is not helpful because viremia does not correlate with end organ damage
  • Culture is not helpful either
  • Tissue sampling is the diagnostic of choice to look for end organ involvement
  • CMV IgM


DDx for Ulcerations in GI Tract in HIV (in addition to etiologies not associated with HIV:

  • HSV (although mostly esophageal)
  • Histoplasmosis
  • Aphthous ulcers (although mostly esophageal)
  • Amoeba




ZSFG AM Report Pearls 3/5/18: Bump it Up, Bump it Up, Watch it All Fall Out: Calling for Help in Necrotizing Faciitis

Thank you to Annie Hargrave for presenting a really challenging case of necrotizing fasciitis. Her case highlights the need to “bump it up” to the attending level when there is any reaonable index of suspicion.


Necrotizing Faciitis:

This topic has been explored fairly well on the chiefs blog: please see Dan Wheeler’s excellent post Here

I compiled this and a few other notes on necrotizing fasciitis into an evernote Here


If You Think It Could Be Necrotizing Fasciitis:

  1. Call general surgery to have them evaluate
  2. Know that the general surgery intern (and even the senior residents) may not have seen enough necrotizing fasciitis to to definitively make the call
  3. Know that on medicine, we often see the atypical cases that have odd presentations (otherwise they would have been triaged to surgery up front)
  4. Don’t be afraid to “bump it up” to the overnight attending, the general surgery senior, AND the general surgery attending. (Again and again and again and again the general surgery ATTENDINGS tell us that they are 100% OK with you calling them if you are worried about necrotizing fasciitis even when the intern says they don’t think it is)
  5. If ever in doubt, unsure, or feeling sheepish about bumping it up, ask for back up!

ZSFG AM Report Pearls 3/2/18: What Blood Goes Up Must Come Down, Spinnin’ Blood Got to Go Round: When Upper GI Bleed Presents as Hematochezia

Thanks to Dr. Cello for dropping some knowledge in AM report about when upper GI bleed presents as hematochezia. The studies on how much blood it takes to cause hematochezia are from the 1940s-1960s, and boy were those some different times……I guess the IRB has trouble approving new studies that have humans ingest blood or “instilling” blood in various places to see how much it takes to come out on the back end…….



  • Can occur with as little as 50mL of blood in the stomach
    • Schiff L, Stevens R, Shaprio N, Goodman S. Observations
      on the oral administration of citrated blood in man. Am J Med Sci. 1942;203:409-412.
  • Blood inserted into the small bowel or cecum can still create melenic stool, depending on how long it takes between blood being present and the patient’s bowel movement.
    • Hilsman JH. The color of feces following the instillation of citrated blood at various levels of the small intestine. J Med Assoc Ga. 1950;39(10):402-405.
    • Luke RG, Lees W, Rudick J. Appearances of the stools after the introduction of blood into the caecum. Gut. 1964;5:77-79.



  • 1 Liter of blood placed in the stomach can result in bright red blood per rectum within 4 hours; this red blood or clots per rectum are due to either very rapid blood loss or a distal source of bleeding.
    • Schiff L, Stevens R, Shaprio N, Goodman S. Observations on the oral administration of citrated blood in man. Am J Med Sci. 1942;203:409-412.


Reminder About NG Lavage in GI Bleed:

  • NG Lavage for determining if patient needs urgent EGD
    • Sensitivity = 81% (67-89)
    • Specificity = 55% (19-87)
    • Positive LR = 2.0 (1.0-4.0)
    • Negative LR = 0.40 (0.20-0.81)
  • Mediocre sensitivity
  • Abysmal specificity, so CANNOT use to RULE OUT


Source: Srygley, D.F. et al. (2012). Does this patient have a severe upper gastrointestinal bleed? JAMA. 307(10):1072-9.


ZSFG AM Report Pearls 3/1/18: Ain’t No Platelet High Enough: Thrombocytosis DDx, Complications, and Treatment

Thank you to the ZSFG team for presenting a great case of a patient with a gluteal abscess who presented with a significant neutrophilic leukocytosis and extreme thrombocytosis. We reviewed the differential, complications, and treatment of thrombocytosis.


Pearls on Etiology:
  • Degree of elevation does not help distinguish reactive (aka seconday) thrombocytosis from primary thrombocytosis
    • One study demonstrated that 82% of pts with plts >1 million were reactive
  • There are presently no diagnostic findings that can definitively distinguish between clonal and secondary (reactive) thrombocytosis.
Differential Diagnosis for Thrombocytosis:
  • Reactive Thrombocytosis (Secondary)
    • Most common
    • Secondary process from surgery, infection, cancer, chronic inflammation
    • Note that occult malignancy could cause this and is difficult to diagnose
  • Familial Thrombocytosis (Familial/Congenital)
    • Rare cases of autosomal dominant disorder, gain of function mutations in thrombopoietin gene
    • However, now recognized as a genetically heterogeneous disorder
  • Clonal Thrombocytosis (Primary)
    • Chronic myeloproliferative disorder
      • Essential thrombocytosis
      • Polycythemia vera
      • May occur in other myeloproliferative disorder but ET and PV are most common (for example, prefibrotic myelofibrosis which can evolve into overt myelofibrosis)
Clinical Complications from Thrombocytosis:
Clonal Thrombocytosis
Secondary (Reactive) Thrombocytosis
Underlying systemic disease
Often clinically apparent
Digital or cerebrovascular ischemia
Large vessel arterial or venous thrombosis
Increased risk
Bleeding complications
Increased risk
Yes, in about 40% of pts
Peripheral blood smear
Giant platelets
Normal platelets
Platelet function
May be abnormal
Bone marrow megakarylocytes (Number)
Morphologic Features
Giant, dysplastic forms w/ increased ploidy, assoc w/ large masses of platelet debrid
Treatment Algorithm:



Source: Schafer, AI. (2004). Thrombocytosis. NEJM. 350:1211-9.


ZSFG AM Report Pearls 2/27/2018: I Don’t Know Much About Algebra, But I Know 1 + 1 = 2: Adding Rifampin to Vancomycin in MRSA Infections

Thank you to our Jackie, Laura, and Lisa for presenting a case of a patient with septic arhthritis and endocarditis. In addition to reviewing a checklist for Staph aureus bacteremia, we dove into the indications for adding Rifampin to Vancomycin for MRSA infections.


Staph Aureus Bacteremia

~50-60% of staph aureus = MRSA
-Blood cultures
-If positive, repeat, if positive, repeat, if positive repeat
-No need to repeat if cultures are still cooking
-Assess lines/hardware other access sites
Obligatory Studies:
1) TTE
2) If LBP, must get MRI (abcess)
-Vancomycin 15mg/kg q12 hours if renal function (call pharmacy for help)
    -Goal trough ~15
-Follow-up on sensitivities and narrow if MSSA
-Follow-up on troughs and make sure your dosing is appropriate
Duration of Tx:
-14 days no matter what (well, negative ECHO, quickly clear cultures)
-4 weeks (if longer time to clear, i.e. >1st f/u set)
-6 weeks (endocarditis, osteomyelitis)
When to Use Vancomycin + Rifampin in MRSA Infections:
  1. Hardware infection
  2. Spinal infection/Osteomyelitis (B-III Recommendation)
  3. Prosthetic valve
  4. MRSA Meningitis
  5. Extensive or ongoing metastatic disease



Source: Liu C et al. (2011). Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clinical Infectious Diseases. 52:e18-55.

ZSFG AM Report Pearls 2/15/2018: Rock You Like A Hurricane – “Secondary Gout” from Lymphoma

Thank to Harry Han for presenting a really interesting case in AM report of a young man with a history of gout who developed pancreatitis and was then found to have a small bowel lymphoma. This case raised many questions but one interesting question was whether the gout in a young man was a canary in the coal mine for the lymphoma….?


Secondary Gout Associated with Myeloproliferative Disorders


  • Gout is caused by hyperuricemia
  • Myeloproliferative disorders can lead to an overproduction of urate from an excessive cell turnover
  • Has been described in polycythemia vera and other myeloproliferative disorders


  • Often the serum urate level is higher than primary gout
  • Multiple joints tend to be involved in secondary compared to primary
  • Possibly more likely to have more extensive tophi and nephrolithiasis compared to primary gout (based on small case series)Secondary Gout


  • Treatment of underlying myeloproliferative disorder
  • Urate lowering therapies just like primary gout!



  • Emmerson, BT. (1996). The management of gout. NEJM. 334:445-451
  • Yu, T. (2005). Secondary gout associated with myeloproliferative diseases. Arthritis & Rheumatism. 8(4):765-771.


ZSFG AM Report Pearls 2/14/2018: Buprenorphine – Upgrade You, I Can Up, Can I Upgrade You?

In our first Addiction Medicine morning report, we had Marlene Martin share some great pearls about how to “upgrade” our patients to Buprenorphine treatment to better treat their opioid use disorder (and possibly chronic pain). Check out some super helpful pro tips on using Buprenorphine.


Buprenorphine Basics:

Goals of Treatment:

  1. Elimination of drug hunger or cravings
  2. No sedation from medication
  3. COWS (clinical opioid withdrawal score) of 5 or less
  4. If patient uses illicit opioids while on Bup, they should not feel substantially intoxicated

Prior to Induction:

  • Verify diagnosis of opioid use disorder
  • Check LFTs (very rarely can cause hepatotoxicity)
  • Check urine pregnancy test
  • Obtain urine tox and run CURES report
  • Assess patient’s recent opioid use (you don’t want to precipitate withdrawal)


  • Start: 4mg (or 2mg if concerned there could be a risk of withdrawal)
  • First Day Dose: Should not exceed 16mg
  • Maintenance: Typically 12-24mg
  • Max: 32mg
  • Dangerous: Technically, there should not be a dangerous dose since partial agonist
  • Contraindications: Typically avoid in the 24-48 hours since last opioid use, but the timing really has to do with the opioid being used (i.e. longer half-life, wait longer)
    • Note that if COWS >= 8, unlikely to precipitate withdrawal
  • Use: If using the film, patients should not swallow (can take up to 20 minutes to dissolve)

If daily dosing => Opioid Use Disorder

If TID dosing => Opioid Use Disorder + chronic pain

Bup Flowchart


Source: “ZSFG Inpatient Management of Opioid Use Disorder: Buprenorphine”