Internal Medicine

Key Points:

• Clinical Presentation: Swelling and tenderness in multiple joints, rash on lower extremities, and elevated inflammatory markers.

• Risk Factors: Multiple sexual partners and substance use.

• Laboratory Findings: Elevated leukocyte count, neutrophilia, elevated ESR, and CRP.

Neisseria gonorrhoeae is known to cause disseminated infections, presenting with symptoms such as tenosynovitis, dermatitis, and polyarthralgia, which matches the patient's symptoms.

Never heard of it.

All?

Kidney-shaped gram intracellular negative organisms consistent with Neisseria gonorrhea @Everyone

If you say spaghetti and meatballs, I would say Malasezzia Furfur (tinea versicolor)

Enterococci, staphylococci and streptococci in that order.

Guillain-Barre is the most common cause of acute neuromuscular paralysis in the world. Many cases follow an obvious antecedent infection and many such infections have been described. One of the most common of these, if not the most common, is gastroenteritis due to Campylobacter jejuni. Other precipitating infections include cytomegalovirus, Epstein-Barr virus, HIV, and Zika virus. The presumptive mechanism for this syndrome is that the antecedent infection evokes an autoimmune response that cross-reacts with peripheral nerve components because of shared epitopes (i.e., molecular mimicry), resulting in an acute ascending demyelinating polyneuropathy. This immune response is directed against the myelin or the axon of peripheral nerves.

Shigella produces febrile diarrhea and may be associated with seizures but not a Guillain-Barre like illness.

Clostridium botulinum is a very rare cause of GI symptoms other than constipation as part of infant botulism; botulism is a descending paralytic illness.

HSV causes meningitis or encephalitis but is not associated with a Guillain-Barré- like syndrome. Enteroviruses can cause diarrhea and aseptic meningitis but not Guillain-Barré syndrome, although there is mounting evidence that enterovirus D68 is associated with acute flaccid paralysis in children.

@Everyone

Strongyloidiasis is common in Southeast Asia, where she had worked, and in many other parts of the world. Infection is acquired by exposing skin to larvae in fecally contaminated water. Infection may be asymptomatic, and because the roundworm may complete its life cycle within the human host, infection may persist for years to decades.

Steroids may result in dissemination of worms that leave the GI tract carrying along with them GI flora. This may result in Gram-negative rod bacteremia, and less commonly bacteremia due to other gut organisms including Streptococcus gallolyticus or Enterococcus. Meningitis due to these bowel organisms may occur either due to direct bacteremia or larval invasion of the CNS.

S. gallolyticus bacteremia and endocarditis may be associated with underlying bowel disease including colon cancer, and colonoscopy should be considered in patients with S. gallolyticus bacteremia. However, this patient’s young age and the onset with corticosteroids make strongyloidiasis more likely.

CSF leak is a high risk factor for bacterial meningitis, but most cases are due to pneumococci or viridans streptococci; S. gallolyticus would be very unlikely.

Common variable hypogammaglobulinemia is typically associated with a history of recurrent respiratory tract infections, a history absent in this case.

Accidental ingestion of dog fleas may result in human infection with the dog tapeworm, Dipylidium caninum, but meningitis is not seen.

@Everyone

The principal concern in this patient is possible BK virus nephropathy.

Although quantitative PCR of plasma or urine has been advocated for diagnosis, the most reliable diagnostic measure is demonstration of the characteristic basophilic inclusions in renal tubular cells on renal biopsy. Seeing these tubular cells in urine cytology, “decoy cells” is too common to be diagnostic, though absence of these cells suggests against the diagnosis.

BK, a polyoma virus, cannot be cultured by routine measures and large quantities can be found by PCR of urine from immunosuppressed patients without nephropathy. Blood may be positive for BK virus but cannot distinguish between BK nephropathy and rejection, which would be treated differently (reduction versus intensification of immunosuppression).

JC virus causes progressive multifocal leukoencephalopathy, not nephropathy. 

Adenovirus would not be expected to cause azotemia in renal transplant recipients.

CMV is extremely unlikely while on prophylaxis and very rarely causes kidney injury.

ORF is a poxvirus (specifically a parapoxvirus) that causes painless lesions at inoculation sites about 14-21 days after inoculation and which ultimately resolve spontaneously over 4-8 weeks. It does not typically cause systemic symptoms or disseminate except in unusual cases in immunosuppressed hosts. There is no therapy.

The patient has a painless ulcerated nodule. The differential might include anthrax, leishmania, or Buruli ulcer: patients are not necessarily systemically ill with any of these entities (with cutaneous anthrax, however, systemic manifestations may develop). This woman had been in the United States for 5 years, making Leishmania and anthrax unlikely. Anthrax is seen primarily in the United States in bison, not domestic animals. Buruli ulcers, due to M. ulcerans, are acquired in Africa, not the United States.

Orf is common in herds of goats and sheep: contact with oral lesions of animals, or with milking them, can lead to this type of lesion. Presumably this woman had contact with an oral lesion in the sheep head and the virus was then inoculated into her skin by the minor trauma.

Similar cases can occur with goats, deer, or with elk. See the lesion in the goat oropharynx below. 

@Everyone TRAPS is a rare, autosomal dominant disorder in which there is a defect in the gene that encodes the receptor for tumor necrosis factor. Patients may present from infancy to the 50s. Recurrent fevers over many years occurring every 5-8 weeks and lasting several days, in the absence of any evidence of infection are typical.

Other features that may be present include myalgias, conjunctivitis, periorbital edema, abdominal pain and monoarticular arthritis. Rash is common, usually manifesting as one or several erythematous patches that may spread distally down an extremity. A minority of patients will develop amyloidosis.

Familial Mediterranean Fever (FMF), an autosomal recessive disorder, may also present in adult life and is characterized by episodic attacks of fever accompanied by polyserositis with abdominal pain, pleurisy, and sometimes arthritis. Rash is very rare in FMF.

In cyclic neutropenia monthly episodes of profound neutropenia occur lasting about a week. Diagnosis typically is made in childhood. The condition appears to be more common among African American children.

Hyperimmunoglobulin D, an autosomal recessive periodic fever syndrome, is characterized by attacks of fever accompanied by chills, enlarged cervical nodes and sore throat, aphthous ulcers, and a pleomorphic rash; IgD levels are elevated.

Chronic granulomatous disease is a disorder of neutrophils in which intracellular killing of certain organisms is impaired leading to recurrent infections, not unexplained fever.

ANSWER: B

Antiretroviral therapy (ART) should be prescribed at the time of diagnosis of HIV infection unless the patient has expressed a desire to not initiate treatment.

ART should not be delayed until the CD4 cell count drops to a predetermined level or until an AIDS-defining illness occurs.

It is recommended to initiate prophylaxis for Pneumocystis pneumonia when the CD4 cell count drops below 200 cells/μ L. when he develops an AIDS-defining illness.

The answer over here is a transthoracic echocardiogram.

Patient most likely has acute right sided IE. Although left sided IE is more common in the general population, those who use IV drugs most commonly develop right sided IE affecting the tricuspid valve.

Staph aureus is the most common cause >50% of the cases. Presentation is typically acute and characterized by high fevers. They often have pleuritic chest pain and cough d/t septic pulmonary emboli, a complication that occurs in 75% cases of right sided IE. The emboli appear on CXR as multiple nodular opacities. Cardiac murmur is sometimes absent in right sided IE and peripheral signs of IE are also not present.

So initially a TTE is done, followed by TEE if indicated.

Patient is at risk for Pneumocystis pneumonia and a bronchoscopy with BAL is used for diagnosis. However, that presentation is usually subacute (3 weeks, low grade fever, non productive cough) and CXR usually shows interstitial infiltrates rather than nodular opacities.

Hi all, thanks for your answers! Patient underwent a TEE and was found to have three hypoechoic formations on the pacemaker electrodes. One month ago on TEE there was only one hypoechoic formation. He had to undergo pacemaker explantation.

ANSWER: C

Of the patients listed, only the patient with a transcatheter-implanted aortic valve is at increased risk of infective endocarditis (IE) associated with dental procedures.

Any patient with a history of valve repair or replacement that involves prosthetic material is at increased risk for IE, but even those with significant valvular disease do not benefit from prophylaxis.

Certain patients with congenital heart disease should also receive prophylaxis, but an isolated atrial septal defect is not associated with an increased risk of IE after dental procedures.

Sepsis may present insidiously, especially in the elderly and immunocompromised. A wide range of symptoms and signs may be associated with infection (including those traditionally thought of as markers of sepsis, such as a high white cell count or C reactive protein); for example, altered mental state, fluid retention, ileus, tachypnoea, and poor peripheral perfusion. In this case a probable source of infection (the intravenous cannula) can be identified. In association with this, SIRS is present (tachycardia and low white cell count) as well as thrombocytopenia, altered mental status, hyperglycaemia in the absence of diabetes, and coagulopathy; hence, sepsis is the most likely diagnosis. Blood cultures should be drawn and broad-spectrum antibiotics started to cover likely pathogens (staphylococcus and streptococcus in this situation). None of the other options can explain the full clinical picture although they may have a contribution to his confusion (especially alcohol withdrawal).

The Monod sign refers to the presence of gas surrounding a mycetoma, typically an aspergilloma, within a pre-existing pulmonary cavity. It is a distinct radiographic feature indicating a freely mobile mass within the cavity that can move when the patient's position changes, optimally observed when images are acquired in a prone position to allow the mass to shift to a gravity-dependent location. This sign should not be confused with the air crescent sign, which is associated with the recovery phase of angioinvasive aspergillosis and indicates an improvement in the patient's condition. Despite the specific implications of the Monod sign, in clinical practice, the term is not widely recognized, and the gas pattern around the mycetoma is often crescent-shaped. Consequently, the term air crescent sign is frequently used interchangeably to describe both phenomena, although they represent different pathological processes.

@Everyone

If patients don't respond to antibiotics, drainage of the abscess is needed. Percutaneous transthoracic drainage is preferred for its simplicity and lower risk of spreading infection compared to transbronchial catheter drainage. Surgery is a last resort, only for abscesses that can't be drained or don't improve with less invasive methods.