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.

Thanks to Dr. Castaneda for an excellent morning report on Dengue and Chikungunya

Learning Points:
— Dengue and Chikungunya present similarly with typical features including fever, arthralgia, mylagia and headache
— Be sure to include both Dengue and Chikungunya on the differential diagnosis for patients who traveled to endemic areas and present with acute febrile illness
— Treatment consists of supportive care including anti-inflammatory agents and analgesics

Click on these review articles on Dengue and Chikungunya for more information

Coronal section of rat brain showing NMDA-R intense reactivity predominantly involving the hippocampus.
(From Dalmau, et al. 2008. Lancet)

Thanks to Thomas Vu and Dr. Mathisen for a great morning report!

Learning points:
– Peripheral blood has 1000 RBC per 1 WBC. Thus, CSF from traumatic taps should have approximately the same ratio.
– CSF glucose should be 0.6 of serum glucose.
– Empiric treatment of bacterial meningitis should include strep pneumoniae and neisseria meningitidis coverage. Add listeria coverage for age >50 and immunocompromised. Add pseudomonas coverage for history of instrumentation/trauma.
– Consider NMDA-receptor encephalitis in women presenting w/ altered mental status + psychosis, dyskinesias, seizure, autonomic instability.
– Here is a great article from Dr. Josep Dalmau of UPenn looking describing the course of 100 patients with NMDA-receptor encephalitis.

Thanks to Amy Wu for an interesting case of neurosyphilis!

Learning Points
-Tabes Dorsalis is a uncommon condition of slow demyelination of the posterior columns of the spinal cord caused by Treponema pallidum and is most commonly characterized by sensory ataxia and lancinating pains in the limbs.
-Although neurosyphilis is uncommon in the antibiotic era, it can occur at any time after initial infection and requires a high level of suspicion in symptomatic patients, particularly those with HIV.
-Treatment includes 10-14 days of IV penicillin G with serial monitoring of CSF until WBC is normal and VDRL is nonreactive.

–Click here for a comprehensive review of all things syphilis!

Thanks to Dr. John Hollowed and Dr. Rohit Godbole for an excellent morning report on APML

Learning Points:
— APML is linked with the t(15;17) translocation involving the RARa gene on chromosome 17 and the Promyelocytic Leukemia (PML) gene on chromosome 15
— APML is associated with DIC and patients are at high risk for intracranial bleeds
— Early recognition is KEY!
— Treatment includes all-trans retinoic acid +/- Aresenic or Anthracycline-based chemotherapy

Enjoy this great review article by Dr. Wang who discovered all-trans retinoic acid for APML

Thanks to Dr. Sue Zhang for an excellent case and presentation of invasive actinomyces!

Learning Points:
-Findings of multiple liver cysts carry a broad differential but include infection (pyogenic, fungal or parasite) and malignancy.
-Abdominal Actinomyces israelii is has been associated with neglected metal IUD’s.
–Click Here for an excellent article on differential and workup of hepatic cysts.

Thanks to Dr. Thomas Vu for presenting an interesting case of Guillain-Barre.

Learning Points:
— Classic presentation includes progressive, symmetric muscle weakness with diminished or absent DTR’s
— Can be accompanied by numbness, paresthesias, weakness and pain in the limbs
— Associated with albuminocytologic dissociation

Click below for a great review article on Guillain Barre

Source: UpToDate

Thanks to Dr. Amy Wu for a great morning report on pulmonary cocci!

Learning Points:
-Primary infections due to Coccidioides sp. most frequently manifest as community-acquired pneumonia (CAP)
-Keep cocci in your differential for a patient presenting with CAP, especially if they are not clinically improving with empiric antibiotics
-There is a wide spectrum of clinical manifestations; from a subclinical, self-limited illness, to a subacute process known as Valley Fever with respiratory complaints, to disseminated (extrapulmonary) disease (most commonly spreading to bones, skin, and CNS).
-Serologies in the acute phase may be falsely negative
-Since uncomplicated primary infections are usually self-limited, the decision to treat with antifungals can be considered for patients on an individual basis.
-For more on this topic, here is a great article by the Journal of Clinical Microbiology