Community-Acquired Pneumonia

(the Stanly Cup, pictured left)

Community-acquired pneumonia is extremely common. When patients present with this condition, we are often faced with a situation in the ER where we either admit pateints to hospital, or decide to treat in an out-patient setting. How do we decide? There are two major ways to do this.....

• "Gestalt": take a careful history and physical exam, look at the bloodwork and chest x-ray, think about the patients' social situation and the time of day (or night), and put all the information into context and make a decision.

• Clinical Prediction Rules: There are a few of these, however the Pneumonia Severity Index (derived from PORT score) and CURB65 score are most widely used.

Pneumonia Severity Index: Here is a link to the original article from NEJM. Points are given for various clinical/historical feaures and patients are categorized into one of 5 classes. Class I, II, have very low all-cause mortality rates at 30 days and can usually be treated as outpatients. Class IV, and V have higher rates of morbidity and 30-day all cause mortality - these patients should be admitted to hospital.

CURB65: This is a much simpler scale requiring only 5 pieces of information. Here is a link to the original article in Thorax. Each feature is worth 1 point...then just add them up.

• C: confusion- disorientation to person, place, time
• U: urea >7 mmol/L
• R: respiration rate >30 breaths per minute
• B: Blood pressure- systolic <90 or diastolic <60 mmHg
  
• 65: age >65 years

30-day mortality rates are 0.6% with a score of 0, and 1.7% with a score of 1. Scores of 4 have roughly 15% 30-day mortality rates - oy vey (come find me if you don't know what that means). Patients with scores of 0 or 1 can most likely be treated as outpatients. 3 points or more should be brought into hospital, and 4 or more points should likely be evaluated by the ICU.

Remember, these scales are helpful tools meant to assist you - they are not substitutions for good clinical judgment.

Gonococcal Infection: a few syndromes

Pictured: Image from NEJM, a case of disseminated GC infection. Click here for the link. Note the tenosynovitis and 'countable' pustules.

Gonococcal Infection - syndromes:

• Localised inflammation of involved mucous membrane: urethritis, vaginitis, pharyngitis, etc.
• Pelvic inflammatory disease
• Fitz-Hugh and Curtis syndrome: inflammation of the liver capsule, from direct extension of the organism in a patient with pelvic inflammatory disease.
• Arthritis dermatitis syndrome: migratory arthralgia, tenosynovitis (Achilles, wrist,etc.), pustular lesions - usually not very many...they are "countable". Fever is common here.
  
• Septic arthritis
• Other very rare: meningitis, endocarditis

Link: updated treatment guidelines can be found here

Arthridites Associated with Inflammatory Bowel Disease

(above: monoarthritis in a patient with IBD)

Spondylitis and Sacroiliitis

• HLA B27 in 50-75% with axial arthritis
• Prolonged morning stiffness which improves with exercise
• Unrelated to GI disease...'disease discordant'
  
• Sacroiliitis may be asymptomatic
• Treatment: Back exercises, NSAIDs, maybe methotrexate
  

Peripheral arthritis

• Type 1
• Acute and pauciarticular peripheral arthritis
  
• Associated with flares of bowel disease....'disease concordant'
  
• Self limited with no joint deformity
• Knee most common site affected

• Type 2
• Polyarticular damage especially at MCPs
• Migratory
• Persist for months
• Can have exacerbations and remissions
• Treatment: NSAID/COX-2, sulfasalazine, methotrexate
  

HIV+ with Shortness of Breath

(a complex parapneumonic effusion pictured left)

Today we discussed the diagnosis and management of Parapneumonic Effusions. Check out some details here.

We also discussed an approach to patients with HIV who present with shortness of breath.

A few things to consider...

• Is this an HIV or non-HIV related condition?
• What is this patient's immune status (last CD4+ count and Viral Load)
• Is this patient on Antiretroviral therapy?
• Is this patient taking the appropriate prophylactic therapy (eg. Septra for PJP)
  
• Are there other Tuberculosis risk factors?
• Can the past medical history help me here?

HIV-related causes of shortness of breath:

1. Infectious

• Community acquired pneumonia: >10x more likely in HIV + patients with CD4+ counts less than 200. Watch out for parapneumonic effusions and empyema. S. pneumoniae is common.
  
• Pneumocystis Carinii Pneumonia or Pneumocystis Jirovecii Pneumonia or PCP or PJP... whatever you want to call it, this is still the most common AIDS-defining opportunistic infection. You can read more on this here.
• Viral: Influenza, CMV
• Tuberculosis must be considered, but also think about non-tuberculous mycobacteria as well, like MAC (usually disseminated rather than pulmonary)
  
• Fungal: Cryptococcus, Histoplasma, Coccidioides. Also think about Aspergillus - though more common in neutropenia.

2. Malignant:

• Lymphoma: non-Hodgkins > Hodgkins
  
• Kaposi's sarcoma and associated Castleman's Disease
• Metastatic disease
  

3. Other:

• Cardiovascular: think about cardiomyopathy or other cardiac risk factors associated with HIV as a cause for shortness of breath
• Pulmonary Hypertension
• Drug toxicity
  
• Inflammatory conditions

A Good Link:

• Here is a great case and approach to shortness of breath in HIV+ individuals.
  

Lemierre's Syndrome

(pictured left: image from NEJM...arrow pointing to a thrombosed jugular vein)

Lemierre's Syndrome

What is it? a septic thrombus of the jugular vein.

Which bacteria are implicated? usually oral flora, and typically Fusobacterium species.

How does one get it? typically after acute pharyngitis, there may be a small abscess or erosion of the mucosa. Bacteria can then invade the peri-pharyngeal space which houses the carotid sheath (encasing the jugular vein), and neck musculature.

How do patients present? more common in younger patients with a prodrome of a sore throat. They commonly have a fever, and possibly tenderness over the thrombosed vein. Septic emboli frequently spread to the lungs so an element of respiratory distress may be seen.

Treatment? use a beta-lactamase resistant beta-lactam. Surgical exploration may be required. The role of anticoagulation is controversial.

A great reference: check out this case

The Solitary Pulmonary Nodule

An Approach to the solitary pulmonary nodule.....

Differential Diagnosis:

• Malignant: can be primary (adenoCa, squamous, large cell, or small cell), or metastatic
• Infectious: Granuloma from TB or fungal infection (eg. histoplasmosis, coccidiomycosis), abscess, aspergilloma
• Vascular: arteriovenous malformation, infarction
• Inflammatory: Wegener's granulomatosis, rheumatoid nodule
• Benign neoplasm: hamartoma, lipoma

Risk Factors for Malignancy:

• Size greater than 3 centimeters
• spiculated border
• "eccentric" calcification pattern (see above image; calcium deposition is off-centre)
• doubling time of the nodule is between 20 and 400 days
• Clinical clues: constitutional symptoms, smoking history

As always:

• Take a good history and physical exam
  
• Get an old Chest X-ray
• If you susptect malignancy: Get a tissue sample with Bronchoscopy vs Video-Assisted Thorascopic Surgery vs Open Thorascopy

A good link:

• approach to the solitary pulmonary nodule from NEJM.

Pancreatitis

We have previously discussed our physical exam and diagnostic approach to Ascites here.

The mainstays of treating pancreatitis includes identifying an underlying cause and correcting it (eg. gallstone, hypertriglyceridemia, hypercalcemia, etc.), pain control and fluid resuscitation. Other issues that should be considered are feeding status and preventing infection.

1. Infection: patients are prone to infection by translocation of gut organisms if pancreatic necrosis is present. There is debate in the literature whether prophylactic antibiotics are indicated, and this uncertainty is reflected in guidelines from gastroenterology societies - one recommends it, one does not. Take a look at this Cochrane review and decide for yourself: http://www.cochrane.org/reviews/en/ab002941.html

2. Feeding: The classic teaching was that we do not feed our patients with acute pancreatitis. Newer evidence suggests that early oral feeding is alright if the patient can tolerate it. Here is a good meta analysis from the BMJ.

This is a good review article from NEJM touching on most of these topics

Physical Exam for Pulmonary Hypertension

Physical Exam for Pulmonary Hypertension:

• JVP: may be elevated with prominent A waves (from right ventricular hypertrophy). CV waves are seen in tricuspid regurgitation. A positive Kussmaul's sign and Abdominal Jugular Reflux will be seen if there is right ventricular failure.
• Inspection of the precordium: look for an apical beat. This may be displaced when left ventricular failure is the cause of pulmonary hypertension. Also look for right ventricular heaves.
• Palpation: palpate for a right ventricular heave and sub-xyphoid impulsations (from RV hypertrophy). You may also find a palpable P2. There may be a pulsatile liver edge from tricuspid regurgitation.
• Auscultation: listen for a normal S1 and loud S2. There may also be a split S2. You may hear a right sided S3 in right ventricular failure, or a right sided S4 in right ventricular hypertrophy. Finally, listen for the murmur of tricuspid regurgitation - a systolic murmur best heard at the left lower sternal border that classically gets louder with inspiration (Carvallo's sign).
• Other: patients may have peripheral edema, and rarely ascites.

Links: here is a good review article on the causes of pulmonary hypertension.

Thyroid Cancers

(psammomma body in Papillary thyroid cancer)

There are many types of thyroid malignancies

• Papillary carcinoma: Very common, spreads via lymphatics, more common in woman (3:1) aged 30-50, very high cure rate. Psammomma bodies are seen on histology.
• Follicular carcinoma: The second most common thyroid cancer behind Papillary. This spreads hematogenously, so distant metastases are more common. It typically presents in the 40-60 year old age group with a cold thyroid nodule. It is difficult to distinguish between a follicular adenoma and carcinoma on cytology - so often a partial thyroidectomy is preferred over a fine needle aspiration for diagnosis.
  
• Medullary carcinoma: This originates from C-cells (involved in calictonin production). This commonly affects families and is associated with the Multiple Endocrine Neoplasia syndromes. We discussed these here.
• Anaplastic carcinoma: These are very undifferentiated tumors. Fortunately they are uncommon as the cure rate is low and life span is usually measured in months

A few other thyroid cancers to remember:

• Lymphoma
• Metastatic disease

Here is a good approach to the Thyroid Nodule.

Less is More...

The Syndrome of "Leser and Trelat" came up today in our discussion. It is certainly not that common, but one we should know about. This is a rapid eruption of seborrheic keratoses which can be pruritic and have an inflammatory base. It is a paraneoplastic condition commonly associated with intraabdominal malignancies - particularly gastrointestinal adenocarcinoma.

Here is a case from NEJM.