Thank you Dr. Joey Tu  for a great presentation on a patient with a mild form of myxedema coma

Learning Points:

• Myxedema coma occurs as a result of long-standing, undiagnosed, or undertreated hypothyroidism and is usually precipitated by a systemic illness
• The main feature that differentiates myxedema coma from severe hypothyroidism is altered mental status (patient doesn’t have to be in a coma to qualify). Other features include bradycardia/low voltage, hyponatremia, and hypothermia
• MUST rule out or consider concomitant adrenal insufficiency because if you administer synthroid before steroids, you can cause the patient to go into adrenal crisis
• T3 is 3x as potent as T4

Thank you Dr. Danny Jimenez for a great presentation on a patient with DRESS secondary to Phenytoin use!

Teaching Points:

• Drug Reaction with Eosinophilia and Systemic Symptoms (morbilloform rash + eosinophilia 50-90%; atypical lymphocytosis 30-70%; elevated LFTs 80%; +fevers; +lymphadenopathy)
• Common Culprit Meds: Antiepileptics, Sulfasalazine, Allopurinol, Vancomycin
• RegiSCAR scoring system helps classify signs/symptoms of DRESS into subcategories of likelihood: exclude; possible; probable; definite
• Tx: STOP offending agent; supportive care; systemic steroids only in patients with severe renal or pulmonary invovlement
• Super helpful table: American Family Physician_Fever and Rash

Thanks to Dr. Shalra Hameed for a great morning report on PCP!

Learning Points:

• Five causes of hypoxemia: low FiO2, hypoventilation, impaired diffusion, shunt and V/Q mismatch
• Pneumocystis jirovecii is actually a fungus and NOT a protozoan as originally thought!
• Predominantly seen in immunocompromised patients including HIV, transplant patients, chronic steroid use, etc…
• Presentation varies, however includes fevers, cough, dyspnea, malaise, hypoxemia
• Diagnosis: PCP DFA (gold standard), sputum PCR, oropharyngeal wash and serology; LDH can also be elevated; however can be a clinical diagnosis in the appropriate patient
• Treament: Bactrim IV/PO (gold standard), Pentamidine, Clindamycin, Primaquine
• Indications for steroid use: A-a gradient >35 or PaO2 <70

Click here to review the data supporting the use of adjunctive corticosteroids for PCP in HIV-infected patients

Learning Points

• Pericardial Effusions–Indications for a pericardiocentesis
  • Hemodynamically unstable (therapeutic)
  • Hemodynamically stable (diagnostic):
    • If suspicious of Purulent, TB, Neoplastic pericarditis
    • Mod-large effusion s/p failed anti-inflammatory tx
• Treatment:
  • COPE Study: Results of the COlchicine for acute PEricarditis (Imazio in Circulation 2005)
    • Colchicine + Conventional Tx (NSAIDS) = Less Recurrence than Conventional Tx alone for the FIRST episode of acute pericarditis
  • Comprehensive systematic review on pharmacologic treatments for acute or recurrent pericarditis. (Lotrionte in AHJ 2010)
    • Colchicine vs standard tx(NSAIDS) (3 studies, 265 patients) Colchicine assoc with reduced risk of tx failure and recurrence
    • Steroids vs standard tx (2 studies, 31 patients): Steroids assoc with high risk of recurrence
  • A Randomized Trial of Colchicine for Acute Pericarditis: (Imazio in NEJM 2013)
    • Multicenter, double-blind trial, randomized; 240 patients
    • Colchicine + conventional tx significantly reduced  rate of recurrent pericarditis