Day #323 - Autoimmune Hepatitis

See approach to massive transaminitis here.

There is a nice NEJM review on autoimmune hepatitis here. The table below is linked from there.

Labs:

• In general, ANA is positive more than 1:80, anti-smooth muscle antibody 1:80, there is an elevated IgG, pANCA may be positive

Treatment:

• Prednisone 20-60mg per day with AZATHIOPRINE 50-100mg per day
• Maintentance with AZATHIOPRINE (or other)
• Goal is normalization of liver enzymes and IgG.

Day #322 - Enterococcal Endocarditis

This patient presented with stroke. This article reviews stroke in IE. This related article reviews the neurologic manifestations of IE.




An original article by Osler on IE!



Some key points:
Mitral Valve IE ~ 10% stroke rate
Mortality is high -- 35% in hospital 52% at one year
Early antibiotic therapy reduces neurologic complications


I have previously blogged about infective endocarditis (see here) including enterococcal endocarditis. The first post goes over the Duke Criteria.



Indications for Surgical Treatment of IE (Native Valve):

• Development of heart failure
• MR/AR with dilating LV, or development of pulmonary hypertension
• Fungal IE or that caused by highly resistant organisms (think of it in MRSA)
• Patients with heart block, cardiac abscess, abnormal chamber-chamber connections
• Recurrant emboli despite ABX
• Class IIb -- large vegetations

Day #321 - Polyarticular Gout

Today we discussed a patient with polyarticular gout presenting with fever and multiple swollen joints.

Precipitants:

Drugs: HCTZ, other diuretics, ASA, pyrazinamine, allopurinol, cyclosporin, other
Foods: Alcohol (red wine), Red Meat, Cheeses
Diseases: Myeloproliferative disorders, hematologic malignancies, renal failure

Diagnosis (how to do an arthrocentesis):

Synovial fluid cell count usually in the 10,000-20,000 range but can be as high as 100,000.

Crystals should be seen -- negatively birefringent needle shaped crystals which are intracellular

Acute Treatment (usually one of):


NSAIDS: I.e. Naproxen 500mg PO BID
Steroids: Intrarticular (i.e. depomedrol 20-40mg) or systemic prednisone (i.e. 40mg x 3 days then taper by 10mg every three days)
Colchicine: colchicine 0.6mg po q1h x3 (diarrhea, nausea) then 0.6 OD-BID (renal dosed)

Long term Treatment:
Weight loss, avoidance of foods and drugs that precipitate

Initiate low dose colchicine if you are going to start anti-hyperuric medications to avoid precipitating an attack

Generally initiate therapy if one/more of: (i) urate nephropathy or recurrent stones (ii) destructive tophi (iii) greater than three attacks per year (iv) greater than 1100mg urinary urate per day

Some advocate for use of 24h urine urate -- if >800 then uricosuric therapy is contra-indicated. Titrate to uric acid less than 360umol/L

Uricosuric therapy:

Probenecid start 250mg BID titrate to 500-1000 BID

Consider vitamin C 500mg PO OD

Consider losartan as an antihypertensive if needed (has uricosuric effect)

Consider fenofibrate

Xanthine Oxidase Inhibition:

Allopurinol 100mg PO OD titrate to effect (usual dose ~ 300mg/day)

I have previously blogged about the approach to the mono/oligo arthritis (and septic arthritis) here.

Day #320 - Hypercalcemia from Presumed Sarcoid

A great case today -- and some good topics were covered by the discussant.

1) Hypercalcemia (previously blogged here)

2) Hepatitis C and its complications including:
* Mixed cryoglobulinemia (image) which can cause a vasculitis
* Membranoproliferative glomerulonephritis (review here)
* Porphyria Cutanea Tarda
* HCV Associated Lymphoma

3) Sarcoidosis (from review)

"sarcoidosis is established on the basis of compatible clinical and radiologic findings, supported by histologic evidence [review] in one or more organs of noncaseating epithelioid-cell granulomas in the absence of organisms or particles"
"as a diagnostic tool, measurement of serum ACE levels lacks sensitivity and specificity"

---

Fascinating --> Evidence exists that sarcoidosis can be caused/exacerbated by HCV treatment with interferon.

Day #319 - Temporal Arteritis

From the JAMA series:

History:

• Jaw Claudication LR + 4.2 LR - 0.72
• Diplopia LR + 3.9 LR - 1

Other historical features not helpful to rule in or out. Most sensitive sign is headache (~70%) other signs and symptoms have sensitivity less that 50%

Physical:

• Beaded temporal artery LR + 4.6 LR - 0.9
• Prominant Temporal Artery LR + 4.3 LR - 0.7
• Tender Temporal Artery LR+ 2.6 LR - 0.8

Other physical exam findings are not helpful to rule in or rule out. Most sensitive is combination of ANY temporal artery abnormality (~75%)

Laboratory:

• Normal ESR LR - 0.2 (96% sensitive)

An review on the diagnosis and treatment of GCA/TA is available here. We discussed the relative merits of TA biopsy when the diagnosis is highly likely. The authors suggest that it is important to confirm the diagnosis because if negative, while it could still be TA, this should prompt a re-evaluation of the diagnosis as up to 50% will have an alternative diagnosis.

We then discussed the relative merits of TMP/SMX prophylaxis for PCP in patients on high dose steroids (Table below) from this meta-analysis. In general, though there is no consensus, PCP prophylaxis should be considered in patients on greater than 30mg of prednisone for greater than three months or those who are on moderate-high dose steroids with another immunosuppressive agent (i.e. patients with Wegner's)

Day #316 - Swine Flu

Today we heard a case of a patient with undelying Wegner's Granulomatosis who presented with several days of fever and cough. Her chest xray showed no infiltrate. The majority of patients with influenza will present with cough (90%) and fever (~70%). Headache, myalgias, arthralgias, fatigue are also common but seen in only 50-60%. There is a rational clinical exam on influenza here.

The nasopharyngeal swab revealed influenza, which was PCR confirmed to be "swine flu"

Influenza evolves by two processes. Antigenic drift, where small mutations occur over time in the surface molecules which gradualy cause waning immunity. This is the basis of seasonal influenza.

Antigenic shift invoves abrupt changes in the surface molecules, often as a conseuqnce of recombination with swine or avian lineages, into a strain to which few in the population are likely to have immunity. This leads to epidemic (and pandemic) influenza.

Treatment of Influenza:

• Supportive care
• In patients admitted to hospital/ICU or those with severe disease or severe undelying co-morbidities should receive antiviral therapy (also give to healthy people with less than 72h of symptoms)
• Oseltamavir (neuraminadase inhibitor -- blocks entry of virus into cell) --> available orally, circulating H1N1 are resistant, circulating H3N2 are likely resistant.
• Zanamavir (neuraminadase inhibitor) --> inhalational only, all are currently succeptible
• Amandadine (M channel inhibitor) --> blocks release of viral RNA into the cytoplasm from the lysosome. Available orally, most H3N2 resistant, many H1N1 succeptible.

I have previously blogged about influenza here, here, and here.

Day #315 - Sepsis with DIC

Today we discussed a great case of SEPSIS (focus of infection unclear) with associated DIC.

SIRS Criteria:
Fever or hypothermia
WBC >12,000 or less than 4,000
HR >90
RR >20


Sepsis = 2 or more SIRS criteria of presumed infective etiology
Severe sepsis includes sepsis with end organ dysfunction or lactate >4

Septic shock includes severe sepsis with refractory hypotension requiring inopressors
I have blogged about Early Goal Directed therapy here. Source control is as essential as broad spectrum antibiotics in the treatment of sepsis.

These are recent guidelines on the diagnosis and management of DIC here. Transfusion of plateletes and factors is limited to patients who are bleeding or at high risk of bleeding (i.e. post-op), therapeutic heparins are limited to patients who have thrombosis, DVT prophylaxis is required.