Thanks to Dr. Nicole Mandich for an excellent presentation on Idiopathic Intracranial Hypertension

Learning Points:

• Predominantly seen in young, obese females of child bearing age
• Classic presentations include headaches, papilledema, sixth nerve palsy , visual disturbances (including diplopia, photopsia and sustained visual loss), pulsatile tinnitus
• Predisposing factors include obesity, OCPs, tetracylines, hypervitaminosis A
• DDx: intracranial masses, obstruction of venous outflow, hydrocephalus, increased CSF production, decreased CSF resorption, malignant HTN, dural vein thrombosis

Click here to review the Idiopathic Intracranial Hypertension Treatment Trial

Thanks to Dr. Patrick Poquiz for an outstanding presentation of AIDS related pulmonary Kaposi sarcoma.

Learning Points:

• Pulmonary Kaposi sarcoma (KS) can present shortness of breath, fever, cough, and hemoptysis. The incidence of KS increases as CD4 count decreases, and KS may be associated with Immune Reconstitution Inflammatory Syndrome (IRIS).
• Diagnosis of KS is definitively made by biopsy, however a presumptive diagnosis can be made by presence of characteristic cutaneous, mucosal, or visceral lesions.
• The mainstay of treatment of KS include highly active antiretroviral therapy, but systemic chemotherapy with daunorubicin or doxorubicin may be required with widespread disease.
• Click here for a NEJM review article on KS.

Thanks to Dr. Jarred Reed for an excellent presentation on workup and management of hypercalcemia

Learning Points:

• Clinical manifestations of hypercalcemia include GI (anorexia, N/V), Neuro (weakness, AMS), Renal (polyuria, nephrocalcinosis), and MSK (fractures, osteopenia) symptoms. Causes may be broken down to PTH-mediated and PTH-independent causes.
• Excess PTHrP (also called humoral hypercalcemia of malignancy) is the most common cause of hypercalcemia with non-metastatic solid tumors, and will result in a low or inappropriately normal PTH level.
• The mainstay of management includes aggressive IVF but may require bisphosphonates, calcitonin, and corticosteroids. Use of Lasix is controversial but should largely be utilized to avoid fluid overload.
• Denosumab may be used for refractory cases of hypercalcemia. Denosumab works on the OPG-RANK-RANKL pathway and prevents bone resorption by limiting RANKL driven osteoclast activity.

Thank you Dr. Julien Nguyen for an excellent presentation on herpes zoster and indications for IV treatment

Teaching Points: 

• Herpes Zoster is a reactivation of VZV in ganglia, leading to acute neuritis with a dermatomal rash, sometimes followed by post-herpetic neuralgia in 10% of patients
• Goal is to initiate treatment within 72 hrs of onset with an antiviral
• Indications for IV tx:
  • Disseminated zoster
  • Severe immunocompromised state
  • Herpes zoster ophthalmicus
  • CNS involvement
  • Significant bacterial superinfection
  • Failed PO therapy
• The Shingles Prevention Study demonstrated that HZ vaccine significantly reduced the morbidity due to HZ and PHN in older adults. Read more from the Journal of Infectious Disease

Thank you Dr. Betty Lai for a great case of hypercalcemia on 10.7.15  presenting as altered mental status!

Learning Points:

• The first diagnostic test to workup hypercalcemia should be PTH
• • Hypercalcemia is due to elevation of ionized or free calcium
  • 40-45% of calcium in serum is bound to protein, mainly albumin.
  • Calcium = serum calcium + 0.8 x (normal albumin – patient albumin)
• >90% of cases of hypercalcemia are either from primary hyperparathyroidism vs. malignancy
• Tx: Only for severe hypercalemia (Ca>14) or for symptomatic cases
  • Acutely (quick onset of of action): IVF; Calcitonin; Dialysis; Loop diuretics
  • Long term: Bisphosphonates

Acute transverse myelitis after DTP vaccine.
T2-weighted MRI showing diffuse cord edema, signal hyperintensity (C3-T6).
From PMID: 16317420.

Thanks to Dr. Nguyen-Fa for a great presentation on transverse myelitis!

Learning points:

• Ddx for upper + lower motor neuron symptoms includes ALS, MS, transverse myelitis, ADEM, compressive myeloradiculopathy, HIV, B12 deficiency, WNV
• Proposed diagnostic criteria of acute transverse myelitis (PMID: 12236201):
  • Sensory/motor/autonomic dyusfunction attributable to spinal cord
  • Bilateral s/s
  • Clearly defined sensory level
  • No compressive cord lesion
  • CSF pelocytosis OR elevated IgG index OR gadolinium enhancement
  • Progression to nadir between 4h – 21 d.
• Treated with steroids +/- plasmapharesis +/- cyclophosphamide

Thanks to Dr. John Feng for a great presentation on severe hypothyroidism

Learning Points:

• Symptoms include: fatigue, cold intolerance, constipation, depression, weight gain, dry skin, hair thinning or loss and memory impairment
• Exam findings include: bradycardia, diastolic HTN, coarse facies, delayed relaxation phase of deep tendon reflexes, non-pitting edema (myxedema), dry skin, hypoactive bowel sound
• Treatment: start IV levothyroxine when there is concern for gut edema (most commonly seen in myxedema crisis) and transition to po levothyroxine at 1.6ug/kg. Please note, start at lower doses in elderly and cardiac patients.

Click on this great article to learn more about hypothyroidism

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: