Monday, 1/7: Pulm/ICU Report
Thank you to Mike T. for presenting!
Man in his 20s w/ h/o atopy, smoke exposure p/w subacute progressive DOE & wheezing w/ inspiratory & expiratory wheezing on exam c/w obstructive airway disease.
- Important exposure history: Pets, mold, hot tub, occupation or in Mike’s words “What do you breathe in that the average person doesn’t?”
- Inhaled corticosteroids should be held 72h prior to PFTs. They shouldn’t influence results prior to 72h so OK to start patients on ICS and then hold them 72h before PFTs.
- Rabih Geha’s obstructive airway disease schema here:
Tuesday, 1/8: HIV/ID Report
Thank you to Mike R. for presenting!
Middle-aged man with h/o IV drug use, HIV not yet in care p/w left shoulder pain, found to have left septic shoulder w/ strep viridans, microcytic anemia, and acute on chronic kidney injury.
- You can page the PHAST team from any hospital to get people w/ HIV connected to care including ART as fast as possible.
- The overall WBC count can be reduced in s/o acute illness, which can artificially lower the CD4 count. Use the percentage to help figure out if the CD4 count is accurate. A CD4 of 200 should correlate with a CD% of about 12-14%.
- Septic joint is most likely 2/2 hematogenous spread. In this case, it was most likely 2/2 direct spread from an abscess containing strep viridans.
- Licking needles or spitting to mix drugs can introduce strep viridans into the blood. Again, another mechanism of entry is suspected in this case.
- When selecting initial ART for a patient, aim for a one pill regimen if possible, consider patient’s comorbidities like CKD, possible interactions with other medications like HCV treatment, as well as adherence and the regimen’s likelihood of becoming resistant. However, HIV/ID team wants to be involved as well to help you make these decisions!
- Integrase inhibitors, like dolutegravir, are more likely than protease inhibitors to decrease the viral load quickly.
Wednesday, 1/9: Hospital Medicine Report
Thank you to Tash for presenting!
Man in his 60s w/ h/o 80 pack year smoking hx presenting with subacute shortness of breath and diffuse wheezing on exam.
- Indications for noninvasive positive pressure ventilation (NIPPV) – BiPAP/CPAP:
- Moderate-Severe COPD Exacerbation
- Respiratory acidosis, pH generally 7.25-7.35
- Cardiogenic pulmonary edema
- Possibly – hypoxemic respiratory failure for immunocompromised individuals
Thursday, 1/10: Intern Report
Thank you to Tash for presenting twice in a week!
Young woman with h/o hydroxycut use p/w subacute progressive abdominal distension & jaundice 2/2 new dx cirrhosis, UMN & sensory deficits, thought to be possibly due to copper deficiency from excessive zinc ingestion from the zinc in hydroxycut.
- Causes: Gastric surgery is most common cause of acquired copper deficiency. Other causes include excessive zinc ingestion, dietary copper deficiency, malabsorption syndromes, and chelation therapy in Wilson disease.
- Most common neurologic findings: Dorsal column disease (like Vitamin B12 deficiency) + spasticity & + Babinski, +/- peripheral small fiber neuropathy in stocking distribution
- Most common heme manifestations: anemia (MCV could be anything) and leukopenia. Thrombocytopenia and pancytopenia are relatively rare.
- One case series and a case report describe hepatic iron overload and/or cirrhosis in five patients with copper deficiency myeloneuropathy. Authors speculated this was caused by secondary deficiency of ceruloplasmin, which oxidizes iron for binding to transferrin, which facilitates iron mobilization.
Thackeray EW, Sanderson SO, Fox JC, Kumar N. Hepatic iron overload or cirrhosis may occur in acquired copper deficiency and is likely mediated by hypoceruloplasminemia. J Clin Gastroenterol 2011; 45:153.
Videt-Gibou D, Belliard S, Bardou-Jacquet E, et al. Iron excess treatable by copper supplementation in acquired aceruloplasminemia: a new form of secondary human iron overload? Blood 2009; 114:2360.
Friday, 1/11: GI Report
Thank you to Zane, one of our awesome new clerkship students, for presenting!
Young woman w/ h/o former alcohol & IV drug use, HCV, cirrhosis presumed 2/2 alcohol p/w decompensation w/ encephalopathy & ascites likely 2/2 non-adherence to diuretics.
- For diuresis, push the spironolactone until you see the UrineNa > UrineK.
- She should be referred for evaluation of liver transplant!
- This person should be treated for HCV to decrease the risk of progression of ESLD and HCC, though if she’s going for transplant, would do it afterward.
DDx for young adult with cirrhosis:
- Tox: Alcohol (can also accelerate other processes like HCV and NASH)
- 10 years of daily alcohol use of 80g for men and 30g for women can lead to cirrhosis, which is important to educate our patients about!
- Infectious: HCV, HBV (vertical transmission)
- Autoimmune: PBC, PSC, autoimmune hepatitis
- Infiltrative: Wilson disease, NASH
- Genetic: Wilson, glycogen & lysosomal storage diseases (like Gaucher’s), alpha-1 antitrypsin deficiency
- Copied from a prior blog post on 3/8/17 (thanks, Sam!)
- In a 1988 Indian studyof 63 young cirrhotic patients of mean age 22 years (Sarin SK, Gut 1988;29:101-107), the most common causes were HBV(50%), followed by alcohol (10%), cryptogenic (19%), and rarely, Wilson disease or alpha-1-antitrypsin deficiency (1% each). Notably, HCV was discovered in 1989 so would have been part of the cryptogenic group in this study.
- A 2014 U.S. study of 219 cirrhotic patients under the age of 40 (Sajja KC, J Investig Med 2014;62:920-926) showed that the most common causes of cirrhosis in patients <40 years old were alcohol(45%), HCV(33%), autoimmune (5%), cryptogenic/NASH (4%), HBV(4%), and PBC/PSC (2%). Notably, this study was single-hospital in Texas. The patients were 69% male, 41% Hispanic, 40% Caucasian, 14% African-American, and only 1% Asian/Pacific Islander, so the prevalence of vertically transmitted HBV is likely different than in the San Francisco population.