Day #161 - Autoimmune Haemolytic Anemia

The last morning report @ TGH. I move to MSH in January.

Today we heard a case of auto-immune haemolytic anemia presenting as symptomatic anemia. The patient may have had a prodromal illness.

This is a great article on AIHA. This one is good too.

In reading these something interesting became clear -- in what appears to be AIHA with a negative DAT there are a few possibilities.

• Subthreshold antibody (below the level of detection with DAT) -- this may be mitigated using a different method of DAT
  
• hereditary spherocytosis
• clostridial sepsis
  
• Two interesting ones include wilson's disease and Zieve's syndrome.

NB: AIHA with ITP (either together or sequentially) = Evan's Syndrome

Day #160 - Acute Hepatitis

I have previously blogged about acute hepatitis, and have linked to a great article on acetaminophen overdose. Please see here.

Day #159 - Fever of Unknown Origin - The Return

Due to fun rounds time constraints -- will point you to my previous blogs on FUO -- here.

Day #158 - TIA (and Stroke)

Today we talked about a case of a patient with a presumed cardioembolic (atrial fibrillation mediated) TIA and evidence of old parieto-occipital stroke.

We discussed the use of anticoagulants such as warfarin in atrial fibrillation and the CHADS2 score. This patient was "warfarin allergic". Often this is an allergy to the dye in the tablets, and one can use dye free tablets.

In these patients you can also consider nicoumalone (Sintrom) which is another oral vitamin K antagonist that is structurally different (and twice as potent). An alternative (though I am unsure of its availability in Canada) is Anisindione.

This is a great review article on the use of oral vitamin K antagonists.

In acute stroke bridging with LMWH or UFH while waiting for a therapeutic INR is usually not indicated

Note that it probably would be indicated in patients with prosthetic valves who have had embolic strokes.

We also discussed TIAs and the ABCD2 score for prognosticating the risk of stroke in TIA.

Day #155 - Complicated anemia

Today we discussed a medically complex patient presenting with subacute anemia. We discussed an approach to anemia with reticulocytopenia. I have blogged about anemia a few times before (here and here (macrocytic anemia)).

This article discusses the issue of pure red cell aplasia in the context of synthetic EPO.

This Toronto study talks about the use of supplemental iron in dialysis patients.

Day #154 - Severe hypothyroidism (Myxedema Coma)

Today we discussed a case of severe hypothyroidism presenting with impaired cognition, bradycardia and hypothermia.

We discussed the treatment of severe hypothyroidism/myxedema coma:

• Supportive care
• IV levothyroxine 200-500mcg then 100mcg q24h until improving then oral 1.6mcg/kg
• After obtaining ACTH, cortisol levels, strongly consider stress dose steroids until concommitant adrenal insufficiency is excluded
• Look for precipitant (infection, MI, other)
• Empiric antibiotics for possible sepsis while awaiting cultures

This article discusses the polyglandular autoimmune syndromes.

Day #153 - Pneumocystis (PCP) Redux

Today we heard a case of PCP pneumonia with a classic presentation. For those of you who will end up doing medical education -- you should start saving up cases during your residency that you can use as exemplars of diagnoses, management, or approaches -- especially if they have key teaching points or interesting imaging. This will also help you for when you are suddenly called upon to provide impromptu teaching.

I have previously blogged in detail about PCP here. This blog links to a number of other blogs and articles that are also useful.