Category Archives: Morning Report

VA AM Report 3.13.18: A cat named Leo

Case summary: Thanks to Rand and Akshai for presenting a great case– an 84M with a history of gout who presented with RUE cellulitis complicated by GNR bacteremia after being bitten by his cat, Leo, who then developed olioarticular arthritis of the R DIP and PIP joints due to gout that improved on anakinra.

Top pearls:

  1. In contrast to Staph bacteremia, GNR bacteremia should trigger you to think of: a shorter duration of therapy  (7-14 days depending on clinical response), faster switch to oral therapy (48-72H afebrile and hemodynamically stable), and no need for surveillance blood cultures.
  2. Non-purulent cellulitis can take 48-72H to show clinical improvement (downtrending WBC count, afebrile, erythema/edema receding), so hold off on escalation of antibiotics!
  3. The pattern of joint involvement is useful in determining your pre-test probability for septic arthritis– it typically causes monoarticular or at least contiguous arthritis in larger joints, rather than the oligoarthritis in the small joints seen in this patient.
  4.  Anakinra (an IL-1 agent) is an option for patients with gout who have contraindications to traditional therapies (e.g. steroids, NSAIDs)

Gram-negative rod bacteremia pearls c/o Andrew Kerkhoff

  • Earlier in the year, Dr. Kerkhoff– ID fellow extraordinaire– gave us some fantastic pearls about GNR bacteremia during an M+M
  •  Source:
    • Community: GU>>>GI>respiratory tract
    • Hospital: GU>>central lines/wound infections>GI>respiratory tract
  • Risk factors:
    • Immunocompromised hosts (stem cell transplant/hematologic malignancy, solid organ transplant, diabetes, HIV, steroids, elderly)
    • Other organ dysfunction (ESLD, ESRD on HD, chronic pulmonary infection)
  • Microbiology:  Klebsiella, Pseudomonas, Enterobacteriacae, SPACE organisms
    • High mortality rate (12-38%)
    • Increasing drug resistance (to CTX/Zosyn)
  •  Therapy:
    • Duration: few RCTs and driven by site/severity of infection/response to treatment, but generally 7-14 days
    • Switch to oral: within 48-72H of normothermia and normal VS
    • Follow-up blood cultures: bacteremia is usually transient and clears quickly with therapy, and the value of repeat blood cultures is unclear given they are rarely positive

Cellulitis pearls c/o Jen Babik

  • In general, we expand antibiotics too soon in cellulitis, as clinical response (e.g. reduction in edema/erythema, decrease in WBC count, defervesence) can take 48-72 hours.Screenshot 2018-03-15 at 7.24.25 PM
  • For patients who are not improving by 72H, in addition to “wrong bug/wrong drug” that would support switching antibiotics, also consider the following:
    • lack of source control (e.g. abscess, osteomyelitis)
    • bacteremia
    • vascular insufficiency (venous stasis or arterial insufficiency + inadequate elevation)
    • alternative diagnosis (e.g. venous stasis, drug reaction, etc.)



VA Ambulatory Report 3.14.18 – The other FUO: Fistula of unknown origin

Okay, fistula of unknown origin is not a real phrase, but today’s case brought up a good discussion about fistulas. Bennett and Huat presented a case of a 50 yo male with air bubbles in his urine found to have a colovesicular fistula possibly due to diverticulitis.

Colovesicular fistula pearls

  • Most common presentation: pneumaturia or fecaluria.  Less common presentations: UTIs, urinary frequency, hematuria.
    • Pneumaturia is a rare manifestation of a UTI and should strongly raise your suspicion for a colovesicular fistula
  • Despite what we may expect, studies have shown urine culture more often grows one species (40-70% of cultures) instead of mixed flora.
  • Thanks Daniel for reminding us the benefit of oral contrast – Abdominal CT with oral or rectal contrast is the test of choice.  IV contrast is excreted renally and can cloud the picture.
  • Next step is identifying the cause of the fistula.  If no cause is identified on abdominal CT, next step is colonoscopy and/or cystoscopy to assess for malignancy given this will change your management.
  • Causes of bowel-vesicular fistulas
    • Diverticular disease: most common cause
    • Post-op
    • Spontaneous
    • IBD
    • Malignancy: Colon, bladder, cervix, prostate
    • Radiation
    • Other
  • Key Management Principles of Colovesicular Fistulas
    • Treat infection if present, but do not need suppressive antibiotics
    • Definitive treatment of fistula with surgery in majority of cases
      • If the cause is non-malignant, minimally symptomatic patient, and considered high surgical risk you can opt for watchful waiting

Check out this American Journal of Surgery article on Colovesicular fistulas.


Evernote link:

ZSFG Report 3.13.18: This ain’t for the best, my histo’s never been worse, so…

Thank you to Kendra M and Annie Luetkemeyer for discussing the case of women with HIV/AIDS and disseminated histoplasmosis, manifesting as a diffuse papular rash and diffuse lymphadenopathy. We learned some great information about etiology, diagnostics, and classic presentations of histoplasmosis.

Histoplasmosis: Epidemiology

  • Most common endemic mycosis in patients with HIV/AIDS; overall declining though in HIV positive patients given success with ART.
  • Inhaled from soil that contains bird and bat droppings.
  • In the US, classically thought about in the Mississippi, Ohio and St Lawrence River valleys. In this hemisphere, also seen in Caribbean and Central America.
  • Worldwide, Histo has been found in all continents except for Antarctica!


Histo: Clinical presentation

Both immunocompetent and immunocompromised hosts can have histoplasmosis infection

  • Immunocompetent host – usually presents as a mild pulmonary infection
  • Immunocompromised host – especially with advanced AIDS (and CD4 less than 200), can have systemic multi organ involvement.
    • Systemic: Fever and weight loss very common in disseminated histoplasmosis
    • Cutaneous: 10-15% of pts with disseminated histo have skin involvement, usually nodules and papules diffusely
    • Gastrointestinal disease: 70% of pts with disseminated histo have GI involvement; lesions include ulcers most often in colon or ileum.
    • Hepatic and splenic involvement : infiltrative liver disease
    • Pulmonary: productive cough, apical infiltrates with cavitation
    • CNS: 5-20% of cases, meningitis or focal brain lesions
  • Common laboratory signs
    • Pancytopenia – can infiltrate bone marrow
    • Isolated elevated alk phos – infiltrative liver picture
    • Ferritin – frequently very elevated in s/o histo infection


How to diagnoses Histoplasmosis

  • Big picture: maintain high clinical suspicion, as may have false negatives in multiple modalities of testing for histoplasmosis.
  • Top three tests for Histo diagnosis:
    • Antigen testing: Urine Histo Ag: 75% sensitive in nonimmunocompromised, and 95% sensitive in immunocompromised.
    • Biopsy of involved organs with PAS stain.
    • Antibody testing: immunodiffusion test and complement fixation are ~90% sensitive in immunocompetent, ~70% sensitive in immunocompromised pts with disseminated disease. May be negative in acutely ill patients and in those who are immunosuppressed.









SFPC Ambulatory Report 3.8.18 – Buboes!

Thanks Soraya for presenting the case of a young male with HIV intermittently on ARVs with a painful groin mass likely a bubo due to LGV.

The following pearls are thanks to Soraya!

Differential for a bubo:
  • syphilis – painless ulcer, followed by LAN (usually b/l)
  • gonorrhea (proctitis)
  • HSV – painful vesicles, LAN (usually b/l)
  • chancroid – painful vesicles that become pustular and exudative  (tx: azithro 1g x1 or CTX 250 IM x1)
  • granuloma inguinale/donovanosis (Klebs granulomatosis) – painless, ulccerative lesions (friable, bleed); tx doxy x3 weeks (or azithro q week x3
  • cat scratch disease (bartonella henselae) – self limited LAN in kids x2-8 weeks; can tx azithromycin immunocompromised host or mod sxs
  • Tularemia – 1200 cases between 2000 and 2010, think ticks, outdoor activity, or with dead animals or skin, summer time, missouri/arkan/oklah. highly infectious (warn lab). tx streptomycin
  • bubonic plaque (y pestis) – fleas, few cases in US but reported. Southwest US. Tx doxy, FQ.
  • lymphoma
  • incarcerated inguinal hernia
  • TB or MAC
  • amebiasis (e. histolytica) – should see signs of invasive coliits wtih diarrhea, dysentery, heme-pos stools
Starts as ulceration (PAINLESS, usually not noticed) –> 2-6 weeks later you get regional tissue invasion & constitutional sxs. will penile, urethral, or vulvar inoculation –> inguinal LAN, whereas w/rectal disease, you get back pain or rectal pain from retroperitoneal LAN.  If you don’t treat the LGV, you get scarring and obstruction of lymphatics, which can cause regional lymphedema and genital elephantiasis (rectal diseaes –> strictures, anal fistulas).
Chlamydia and LGV (tips from Mark Jacobson): 
1.      All patients with clinical proctitis (e.g. tenesmus, rectal discharge) should have a standard rectal swab submitted for chlamydia nucleic acid testing (click on Chlamydial rectal TMA [PHL] when browsing in the Treatment/Labs section of eCW), AND a separate rectal swab in viral transport media (same tube and swab you use to submit a swab for herpes simplex) for LGV. For the latter, click on Chlamydial TMA Other (PHL) when browsing in the Treatment/Labs section of eCW and complete the PHL lab requisition attached to this memo with patient, clinician, and insurance info required, print, and give to our lab.
2.      LGV testing should only be ordered on a rectal swab obtained from a patient with clinical proctitis.  The LGV assay is not validated for other specimens, and asymptomatic LGV infection is not a clinically significant entity.
3.      Patients who have a positive rectal Chlamydia result can be treated with single dose azithromycin IF they have no symptoms or signs of proctitis.
4.      Patients who have a positive rectal Chlamydia result and signs or symptoms of proctititis should receive a one to three week course of doxycycline 100 mg bid, depending on the severity of symptoms.
5.      Patients have a positive rectal Chlamydia result, signs or symptoms of proctititis, and a positive LGV test result should receive a full three week course of doxycycline 100 mg bid.
6.      Note that the LGV assay will not be done if the simultaneously submitted standard rectal chlamydia assay result is negative.
Evernote link:

VA Ambulatory Report 3.7.18 – TB in clinic

Thanks Chris for presenting your patient who is an elderly man with a history of CAD and HTN who presented to clinic with history of tuberculosis and chest xray findings of apical scaring and pulmonary nodules.  We had a great discussion about the challenge of diagnosing TB and management strategies for active and latent TB in the outpatient setting.

TB Epidemiology

  • In countries with a low incidence of TB such as the US, the most common cause of active TB is reactivation of old disease.
  • In San Francisco the most common risk factor for TB is being foreign born in particular individuals from China, the Philippines, and Vietnam.
    • Check out this SFDPH Disease Control and Prevention Report for more epidemiology of TB in San Francisco.

Diagnosing TB 

  • Tuberculin skin testing (TST) vs. Interferon Gamma Release Assay (IGRA)
    • The decision to use TST vs. IGRA is based on patient characteristics, local resources, and cost.
    • The CDC recommends sending IGRA testing over TST in patients you have decided to test due to risk of exposure AND have a history of BCG vaccination or are unlikely to return for ppd read.
    • In other adult patients TST or IGRA are reasonable testing choices, although IGRA is slightly preferred due to better test characteristics (it is more specific)
    • A negative reaction in either test does NOT exclude TB
  • Sputum – AFB smear, culture, and gene expert
    • The policies at our hospitals have been updated and you only need 2 AFB smears and gene experts to decide about airborne isolation discontinuation for inpatients
  • Check out these clinical practice guidelines on the diagnosis of TB.

Management of TB

  • Is this active TB?
    • The diagnosis of active TB is based on symptoms, imaging, sputum AFB smear, culture, and gene expert
    • If a diagnosis of active TB is confirmed, most patients will be treated with directly observed therapy at TB clinicW
  • Which patients with LTBI should be treated?
    • There is a push these days to treat nearly all patients with confirmed LTBI if the patient agrees to be treated
    • There is a strong recommendation to treat patients who are at high risk of reactivation
      • Risk of activation in immunocompetent host is 5-15% over their lifetime
        • ~5% risk within the first 2 years of exposure and ~5% risk over the rest of the lifespan
      • Risk factors for reactivation TB or high incidence of TB: age (young children and elderly), HIV, meds that inhibit cellular immunity (TNF alpha inhibitors, steroids), history of head and neck or hematologic malignancies, organ transplant candidates/recipeints, ESRD, silicosis, low body weight, history of bypass surgery, prisoners, illicit drug use, smokers, homelessness, healthcare workers, foreign born, diabetes, or recent seroconversion.
    • Treatment regimens: Should be based on patient preference, comorbidities, side effects, and drug interactions
      • INH for 6-9 months
      • Rifampin for 3-4 months
      • INH + Rifampin for 3-4 months
      • Rifapentine + INH for 3 months

More TB related resources

Evernote link:


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!