Features and etiology of infectious proctitis in MSM. From PMID: 24275725

Thanks Dr. Jimenez for a great morning report discussing causes of infectious proctitis. 

Learning points:

• Causes of rectal pain include infectious etiologies, IBD, trauma, anal fissures, hemorrhoids.
• In HIV-positive patients, consider gonorrhea, chlamydia (both LGV and non-LGV), HSV, CMV, entamoeba histolytica, and syphilis.
• When testing for stool OxP, collect three daily samples to increase yield.
• For eosinophilia, use the mnemonic NAACP (neoplasm, allergy/asthma, adrenal insufficiency, collagen vascular disease, parasites).
• If suspected, consider empirical treatment of gonorrhea+chlamydia with ceftriaxone 250mg IM x1 and doxycycline 100mg PO BID (covers both LGV and non-LGV chlamydia) while awaiting test results.

It’s October already! Here are some fun events for the weekend:

• San Gabriel Dumpling and Beer Fest is tonight (10/1) at 6pm. It’s being billed as a “local twist on Oktoberfest.”
• Donut lovers should head out to the Madison Avenue Graffiti House 11am-2pm on Saturday (10/3). “Stuff your face at The Los Angeles Donut Festival with donuts and coffee, then finish it off with a donut burger as you vote for Best Donut in Los Angeles: People’s Choice!”
• Vegan Oktoberfest is in LA from 12-5pm, 10/3-10/4.
• The 2015 LA Bluegrass Situation is at the Greek Theatre 2pm at on Saturday, (10/3).

Your LA weekend forecast from weather.com:

Medical illustration of non-typhoid salmonella. From: CDC.gov

Thanks to Dr. Ponec for a great morning report on non-typhoid salmonella causing severe sepsis and diarrhea. Learning points:

Assessing diarrhea:

• Duration: acute (<14d) vs. persistent (14-30d) vs. chronic (>30d)
• If acute, judge severity (number per day, hypovolemia, elderly/immunocompromised, duration)
• Acute diarrhea work-up:
  • Inflammatory? Stool WBC have sens 70%, spec 50%. Calprotectin sens and spec >90%. If positive, consider campylobacter, non-typhoidal salmonella, ETEC, shigella, vibrio
  • Timing? 2-6hr = preformed toxin (s. aureus, b. cereus), 8-16hr = c. perfringens, >16hr = e. coli, viral
  • Bloody? If yes, then consider EHEC, Shigella, Campylobacter, and Salmonella.
  • Stool culture
  • Stool OxP if recent travel or from developing country
• Chronic diarrhea work-up:
  • Watery? Secretory vs. osmotic (check stool osm gap). If osmotic, consider laxative use or carbohydraate malabsorption (low stool pH). If secretory, consider chronic infection (e.g., giardia, c.difficile, campylobacter, cyclospora), microscopic colitis, or neuroendocrine (e.g., VIPoma, gastrinoma, carcinoid syndrome).
  • Fatty? Stool quantitive fat to r/o malabsorptive process
  • Inflammatory? Stool WBC/calprotectin, culture
  • Blood? Consider IBD, malignancy

Non-typhoid salmonella:

• Symptoms generally within 6-72 hours of ingestion
• 1-5% of patients w/ GI infection will have bacteremia
• Extra-intestinal sites of infection include urinary tract, bone, meninges, sites of atherosclerotic plaque
• Treatment with ciprofloxacin or cephalosporin

Learning Points:

– Ectopic thoracic endometrial tissue most commonly presents in young women as a right sided catamenial pneumothorax (~70%) or catamenial hemothorax (~15%).

-One needs a high clinical suspicion for diagnosis, and patients with suspected thoracic endometriosis should undergo contrast-enhanced CT scan which may show a parachymal nodule or cavity.

-Diagnosis is confirmed with direct pleural visualization with VATS procedure.

-Treatment includes endometrial implant resection and possible surgical pleurodesis. Hormonal suppression is also suggested for 6-12 months, either with GnRH analogs or OCPs.

Thank you Dr. Tony Hung for well organized and informative presentation on malaria!

Learning Points: 

1) Among returning travelers presenting with a systemic febrile illness, the most common specific diagnoses are:

• Malaria
• Dengue fever
• Mononucleosis (2/2 EBV vs. CMV)
• Rickettsial infection
• Typhoid fever

2) Test for malaria in any patient with a history of fever and recently in a malaria-endemic region (even if afebrile at the time of evaluation)

3) Most common sx: Fever, headache, myalgia, N/V, abdominal pain, diarrhea

4) Diagnosis: +Parasites on thick and thin peripheral blood smears

5) Here is a great Table from UpToDate organizing various infectious diseases based on their incubation periods

Thank you to Dr. Nandita Sriram for an excellent review of vertigo!

Learning Points:

— Taking a good history is pertinent in distinguishing between dizziness vs true vertigo

— Differentiate between peripheral vs central etiologies of vertigo

• Peripheral causes: BPPV, vestibular neuronitis, meniere disease, acoustic neuroma, otitis media, aminoglycoside toxicity, perilymphatic fistula, Ramsey Hunt syndrome
• Central causes: vestibular migraine, brainstem ischemia, cerebellar infarction or hemorrhage, chiari malformation, multiple sclerosis

— Characteristic physical findings for peripheral etiologies include horizontal or horizontal-torsional nystagmus which suppresses with visual fixation, whereas with central etiologies, characteristic findings include horizontal, vertical or torsional nystagmus which does not suppress with visual fixation

— MRI is only indicated if there is a high clinical suspicion for central causes and exam with pertinent neurological findings

— Enjoy these great review articles on vertigo and BPPV!

Thank you Dr. Jarod DuVall on a very interesting case in a non-diabetic patient presenting with hypoglycemia

Learning Points: 

• True hypoglycemia in a patient without underlying diabetes must fulfill the Whipple’s triad:

1. Presence of symptoms suggestive of hypoglycemia (e.g. diaphoresis, palpitations, tremors)
2. Document that glucose is low when the symptoms are present
3. Demonstrate that symptoms are relieved by correction of the hypoglycemia by administration of glucose or glucagon

• In a patient with asymptomatic hypoglycemia, worry about hypoglycemic unawareness from shifted glycemic thresholds secondary to repeated episodes of hypoglycemia
• Ddx: Meds (Insulin, sulfonyureas); ETOH abuse in setting of depleted glycogen stores; critical illness; malnourishmend; cortisol deficiency; nonislet cell tumor; endogenous hyperinsulinism (e.g. insulinoma); insulin autoimune hypoglycemia (will often present as post-prandial hypoglycemia)
• Consider chronic opiate use as a cause for secondary adrenal insufficiency resulting in cortisol deficiency and ultimately hypoglycemia.
• Here is a case-report on a patient presenting with AMS and seizures from hypoglycemia secondary to an insulinoma

Thanks to Dr. Nicole Mandich for a great presentation on Multiple Myeloma

Learning Points:

— Diagnostic Criteria for multiple myloma

• bone marrow plasma cells>10%
• serum monoclonal protein >3g
• organ dysfunction (CRAB criteria): Hypercalcemia (serum calcium >11.5 mg/dl [2.88 mmol/liter]), Renal insufficiency (serum creatinine >2 mg/dl), Anemia (hemoglobin <10 g/dl or >2 g/dl below the lower limit of the normal range) and Bone disease (lytic lesions, severe osteopenia, or pathologic fracture)

—  Workup includes:

• chem 10, CBC
• SPEP, UPEP, SPIF, UPIF
• bone marrow aspiration and biopsy
• Serum albumin, LDH, beta-2 microglobulin, CRP
• Metastatic bone survey: skeletal survey + PET, low dose whole body CT, MRI spine/pelvis

— Enjoy this great review article on Multiple Myeloma for more details

Thanks to Dr. Nandita Sriram for presenting an interesting case of atypical metastatic colorectal cancer to bone and lung.

Learning Points:

– Colorectal cancer most commonly metastasizes to lung and liver, but may also metastasize to bone. When this occurs, it often presents as a mixed osteoblastic and osteolytic lesion on imaging.

– Follow up of treated colorectal cancer involves serial CEA measurements (q3-6 months for 2-3 years), annual CT of C/A/P for 3 years, and surveillance colonoscopies at year 1, year 3, then q5 years.

– Appropriate surveillance may drastically improve mortality rates of recurrent cancers, as seen in this link to the NCI’s Surveillance, Epidemiology, and End Result (SEER) program: SEER