We had actually discussed this case before in early August. At that time there were no myoclonic jerks, mri abnormalities, or eeg triphasic spikes suggestive of the diagnosis (now presumed) of CJD (from nejm or here from CID).
The previous discussion points on acute confusion, aphasia, and neurosyphilis are available here.
Wednesday, September 10, 2008
Tuesday, September 9, 2008
Day #71 - TTP
Today we heard about a case of a young man with a diagnosis of TTP.
I have previously talked about anemia (including approach to haemolytic anemia) and thrombocytopenia separately.
Day #70 - Fever of Unknown Origin III
I missed the rounds -- but have discussed pyrexia of unknown origin twice before. #1 and #2. Probably not as good as the discussant, but I referenced the article they were referring to.
"Special Guest Blog" by the discussant:
"Special Guest Blog" by the discussant:
- Even in the "modern era", up to 1/3 of cases may go undiagnosed -these cases carry a good prognosis.
- Infections only account for 1/4 of all diagnoses.
- In certain cases without diagnosis, the benefits of liver biopsy outweigh the risks.
- Bone marrow cultures are of low diagnostic yield. Bone marrows should be performed only when there are other indications to do so ie unexplained cytopenias.
- I recently cared for a patient with FUO whose Hodgkin's disease was diagnosed on liver biopsy alone. Patients with FUO are challenging to investigate, are rewarding by virtue of the enigmatic causes that are may be found and reinforce the importance of basic principles like the careful history and physical examination.
Monday, September 8, 2008
Day #67 - Malignant Ascites
Previously I have talked about cirrhosis, ascites, and paracentesis.
The take home point from today's case was that you should be suspicious of a malignant cause of ascites when there is massive ascites without leg edema. The overwhelming majority of patients with ascites from portal hypertension will have leg edema. In this case the cause was an adenocarcinoma seen on cytology.
TB peritoneal disease can mimic a cancer. In fact, sometimes tumour markers such as CA-125 are elevated in TB peritoneal disease mimicking ovarian cancer. The diagnosis of TB peritonitis can be difficult.
The cell count is usually in the hundreds with a lymphocytic predominance.
The SAAG is usually <11.
Adenosine deaminase may be elevated -- if you can measure it.
Obviously the cytology for malignancy will be negative; however, the ascitic fluid rarely stains positive for AFB and the cultures are often negative. AMTD has a higher yield, but it is still disappointing.
Diagnosis usually requires a peritoneal biopsy sent for AFB stain as well as MTB culture.
There is a great nejm case of TB peritonitis here.
A huge (and awesome) free textbook on tuberculosis is available online here.
The take home point from today's case was that you should be suspicious of a malignant cause of ascites when there is massive ascites without leg edema. The overwhelming majority of patients with ascites from portal hypertension will have leg edema. In this case the cause was an adenocarcinoma seen on cytology.
TB peritoneal disease can mimic a cancer. In fact, sometimes tumour markers such as CA-125 are elevated in TB peritoneal disease mimicking ovarian cancer. The diagnosis of TB peritonitis can be difficult.
The cell count is usually in the hundreds with a lymphocytic predominance.
The SAAG is usually <11.
Adenosine deaminase may be elevated -- if you can measure it.
Obviously the cytology for malignancy will be negative; however, the ascitic fluid rarely stains positive for AFB and the cultures are often negative. AMTD has a higher yield, but it is still disappointing.
Diagnosis usually requires a peritoneal biopsy sent for AFB stain as well as MTB culture.
There is a great nejm case of TB peritonitis here.
A huge (and awesome) free textbook on tuberculosis is available online here.
Thursday, September 4, 2008
Day #66 - Chemotherapy Induced Cardiomyopathy
Today we heard a case of congestive heart failure in a patient who had previously received chest radiotherapy and doxorubicin (adriamycin) as part of her chemotherapy for breast cancer. Doxorubicin has the potential to cause an irreversible cardiomyopathy, and in the absence of known cardiac disease in this patient this was likely the cause of her cardiomyopathy.
There are multiple causes of cardiomyopathy including, but not limited to:
There are multiple causes of cardiomyopathy including, but not limited to:
- Ischemic - secondary to MI/ischemia
- Toxic - E.g. adriamycin, alcohol
- Restrictive - Due to deposition of sustances such as amyloid, iron (hemochromatosis), glycogen breakdown products (Gaucher's), idiopathic
- Infectious - Viral (coxsackie virus, HIV), Chagas disease
- Auto-immune
- Genetic - familial dilated cardiomyopathies, hypertrophic cardiomyopathy
- Post-partum
Wednesday, September 3, 2008
Day #65 - Endocarditis
A confession -- today's case was "recycled" for your benefit -- and so is today's blog.
I have previously blogged on endocarditis, renal failure, and hyperkalemia and direct you to those sections.
I have previously blogged on endocarditis, renal failure, and hyperkalemia and direct you to those sections.
Tuesday, September 2, 2008
Day #64 - ACLS
Today we reviewed the crash cart and the pulseless VF/VT/asystole/PEA algorithms. Here is the promised link to the ACLS materials.
http://chiefmedicalresident.blogspot.com/2008/07/day-2-acls.html
http://chiefmedicalresident.blogspot.com/2008/07/day-2-acls.html
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