Phlegmasia cerulea dolens. From PMID: 17229945

Thanks to Dr. van den Burg and Julien Nguyen, PGY2 for a comprehensive introduction to lower extremity DVT management!

Learning points from today:

• When to treat?
  • Assess for contraindications.
  • No bleeding risk score developed specifically for anticoagulation in VTE, but for HASBLED score is being used for anticoagulation in atrial fibrillation. (PMID: 20299623)
  • All proximal DVT should be treated (popliteal, femoral, iliac vein)
  • Symptomatic distal DVT generally treated.
  • Asymptomatic distal DVT may undergo serial U/S surveillance.
• For how long do we treat?
  • 3 months for active episode of VTE.
  • Treating beyond 3 months (i.e., indefinitely) is for “secondary prevention,” typically done if active cancer or 2+ unprovoked VTE.
  • See this great Blood article for a great review of the literature regarding treatment duration. (PMID: 24497538)
• Treatment options
  • Factor Xa inhibitors:
    • Parenteral: Some LMWH (enoxaparin, dalteparin, tinzaparin, nadroparin)
    • Oral: rivaroxaban, apixaban, edoxaban.
  • Direct thrombin inhibitors (No “x” in generic name):
    • Parenteral: bivalirudin, argatroban, desirudin.
    • Oral: dabigatran.
  • Coumadin
• Idarucizumab as a reversal agent for dabigatran is undergoing expedited FDA approval.  (PMID:  26095746, 26095632)
• Consider IR and/or vascular surgery consult for catheter-directed thrombolysis or thrombectomy if evidence of ischemia due to decreased venous outflow (e.g., phlegmasia cerulea dolens, phlegmasia alba dolens).

Thanks to Dr. Hahr for a great morning report on an unfortunate case of anaplastic thyroid carcinoma, a rare disease with very poor prognosis.

Learning points from today’s case:

• Symptoms: When evaluating neck masses, make sure to screen for symptoms of compression: Dysphonia, Dysphagia, Dyspnea.
• Physical exam: Thyroid nodules in the setting of vocal cord paralysis (LR 18), cervical lymphadenopathy (LR 8), or fixation to nearby structures (LR 8) are highly suspicious for carcinoma. 
• Diagnostics: FNA is an acceptable initial approach to obtain head and neck mass tissue due to availability and  lower morbidity. Studies have shown sensitivity >90% for malignancy using this approach (PMID: 11568593, 24350168).   However, LN excisional biopsy is still preferred for LN architecture when feasible and suspicious for lymphoma, and core biopsy may have higher diagnostic yield (PMID: 22127851).
  
• 20-30% of patients with anaplastic thyroid carcinoma have coexisting differentiated thyroid carcinoma.

Thank you to Dr. Delani Gunawardena for an excellent case of an atypical presentation of Crohn’s disease!

Learning Points:

-Crohn’s disease may present atypically, and extraintestinal manifestations commonly include involvement of the mouth (stomatitis), eyes (uveitis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum), and joints (seronegative spondyloarthropathy).

-Most extraintestinal manifestations of IBD will respond to treatment of underlying bowel disease.

–Click here for an excellent review article describing the extraintestinal manifestations of IBD.

Thank you Dr. Betty Lai for a great case of gout presenting as acute monoarthritis

Learning points:

–Acute inflammatory monoarthritis should be regarded as infectious until proved otherwise
–Septic arthritis is an orthopedic emergency
–Most common causes of infectious arthritis in a healthy adult is Staphylococcus aureus, Strepotococcal species, and Neisseria gonorrhoeae
–The typical attack of acute gouty arthritis includes the following clinical features severe pain, redness, warmth, swelling, and disability, with maximal severity of the attack usually reached within 12-24 hours.
–Synovial fluid: <2,000 WBC/mm3 = noninflammatory;  ≥2,000 WBC/mm3 is considered inflammatory
–Click here for an Algorithmic Approach to the patient with monoarticular pain
–Click below for a great review article on Gout

Thanks to Dr. Godbole for an excellent case of disseminated MAC in a patient with HIV!

Learning Points:

-MAC are ubiquitous organisms which commonly cause disseminated disease in HIV patients with a CD4 count of <50.

-Common presentations include diarrhea, abdominal pain, fevers, weight loss, and lymphadenopathy. Diagnosis is confirmed by isolation of MAC from the blood, lymph nodes, or bone marrow.

-Treatment includes combination clarithromycin with ethambutol +/- rifabutin. Intestinal lymphangiectasia (as supected in the presented patient) can lead to malabsorption of HAART and MAC therapy causing refractory disease.

-Click here for a great review of opportunistic MAC infection in HIV patients.

MRSA hypopyon. From PMID: 20234775.

Thanks Betty Lai for a fascinating case of Group B strep infective endocarditis presenting as hypopyon. Great job to all the participants in getting the diagnosis purely from the history!

Learning points:
– When evaluating multi-organ system damage, consider metastatic infective endocarditis in your differential.
– Obtain blood cultures prior to antibiotics. If patient is stable and infection is subacute, goal of 3 blood culture for maximal sensitivity.
– Initial treatment is highly dependent on patient’s predisposition for bacterial species (e.g., native valve vs. prosthetic valve, dental work vs. IVDU). Consider ceftriaxone and vancomycin as initial treatment in acute bacterial endocarditis of native valve.
– New PR interval prolongation in the setting of bacteremia is suggestive of perivalvular abscess affecting AV node (PPV of 88%!).
– Group B strep is rare as oropharyngeal flora (~5%), but causes an aggressive bacteremia.
– Here are the ACC/AHA and IDSA joint guidelines on endocarditis management, and a more recent review of the literature in NEJM.