Infective endocarditis

Morning report today was a case of presumed endocarditis in a VERY susceptible host. See a prior post here with a link at the bottom to the AHA 2008 update.

ECG limb-lead reversal

Amuse-bouche yesterday was an ECG with limb-lead reversal. These are important to pick-up as some can mimic clinical scenarios.
Findings and clinical mimics of common limb-lead changes:
Right arm-Left arm:

• Q wave I, aVL


• Inverted p-wave I, II, II, aVF


• Mimics: old lateral infarct, non-sinus atrial activity, dextrocardia (limb lead reversal will still have normal R-wave progression, dextrocardia will not)

Right arm- Left leg:

• Q wave II, III, aVF


• Inverted p-wave II, III, aVF


• Mimics: old inferior infarct, non-sinus atrial activity

Right arm- Right leg:

• Diffuse low voltage in limb leads (esp. lead II)


• Mimics: any condition causing low voltage (limb-lead reversal will have normal precordial voltages)

Other limb lead reversals causing only minor changes with no real clinical mimics include Left arm- Left leg, Left arm- Right leg and leg-leg reversals. Precordial lead changes will interfere mostly with R-wave progression.

More from an old but concise review here.

Thrombotic thrombocytopenic purpura

Morning report today was a great case of Thrombotic thrombocytopenic purpura (TTP). Please see here for a prior post on TTP, with links at the bottom to two good NEJM articles.

Mesothelioma

AB today was on mesothelioma.

A few points on mesothelioma, with more in NEJM here:
–Malignancy of pleura (<90%) or peritoneum (>10%)
–~90% of patients will have a history of exposure to asbestos, with mean time from exposure to diagnosis ~35y (wide range)

-Usually presents with local pain, cough or dyspnea, and often assocaited with weight loss/fatigue

- Pleural biopsy (VATS or open) is usually definitive, but special stains are required to differentiate from adenocarcinoma

- Despite some advances, including agressive multi-modal therapy (chemo/radical surgery/radiation) and new active agents (pemetrexed), survival is poor with <10% surviving past 2 years.

- Although Canadian and US incidence is dropping (likely due to asbestos regulation), the overall worldwide incidence is increasing- for which Canada is playing no small part (see here).

Hyponatremia

Morning Report today was on hyponatremia. See an old post here for a good overview. There are two good papers linked at the bottom of the post.

Familial Adenomatous Polyposis

Amuse-bouche today was Familial Adenomatous Polyposis (FAP). This results from a mutation of the tumor suppressor gene APC on chromosome 5. A quick review of the features:

Develop hundreds of adenomatous colon polyps during adolescence

Have a 100% risk of developing colorectal cancer (mean age ~40y)

Associated with:

• Upper-GI tumors: Fundic gland polyps, duodenal adenomas



• Adenocarcinoma of the ampula of Vater



• Extra-intestinal features: osteomas, desmoid/soft-tissue tumors, retinal pigment hypertrophy

Here is a link to a basic BMJ review on hereditary colorectal cancer.

Renal failure in multiple myeloma

Today in morning report, a good case of renal failure in multiple myeloma. A good prior post on all of the causes here with a link at the bottom to a review article.

Dermatomyositis

Amuse-bouche today was Gottron's papules and dermatomyositis. A prior post on dermatomyositis here.

A quick review of the associated dermatologic findings:

Gottron’s papules-80% of patients

Hyperkeratotic, erythematous, flat papules

Dorsum MCP and IP joints, less commonly wrists/elbows/knees

Heliotrope rash- <50% of patients

Periorbital violaceous/erythematous rash

One or both eyelids

May be accompanied by edema

Shawl sign

Macular erythema in V shape at nape of neck

Mechanic's hands

Rough and scaly with fissuring

Lateral and palmar areas of fingers

Nail changes

Periungal erythmea

Telangiectasias on the proximal nail fold

Renal failure and hyperkalemia

In morning report today was a case of acute renal failure. A good prior post with a link at the bottom to a good NEJM article here.

We didn't get in to the management of hyperkalemia, but as Dr. Bunce said- you should know it by tomorrow, so here is a prior post with a good link to a review at the bottom.

Pendred's syndrome

The amuse-bouche today was Pendred's syndrome. A link to a good article here.

Pendred's syndrome is an autosomal-recessive disorder of iodine organification caused by mutations in iodine transport protein pendrin.
It is characterized by the combination of congenital sensorineural hearing and goiter, and accounts for up to 10% of cases of hereditary deafness.
Patients have a positive perchlorate discharge test because they cannot provide substrate for the organification step in thyroid hormone synthesis.

Decompensated cirrhosis

Morning report today was a case of fever and decompensated cirrhosis. A prior post on cirrhosis with a link to a good lancet article on management here.

A reminder of the Child-Pugh score above, with total points giving grades A (5-6 ) B (7-9) and C (10-15) and higher mortality with inreasing points/grade.

Seizures and alcohol withdrawl

Morning report today was a case of seizure, more on seizure related topics here.

We also discussed alcohol withdrawl, which has a good blog post previously here.

Plasmacytoma and multiple myeloma

Today's amuse-bouche was a plasmacytoma of the skull. More from NEJM here.

Related is a prior post on multiple myeloma here.

CLL and stem cell transplants

Today in morning report, and interesting case of fever in CLL. Here is a link to a prior post on CLL and immunodeficiency; see the bottom of the post for a link to the role of IVIG: http://morningreporttgh.blogspot.com/2010/04/cll-and-its-complications.html
The other discussion was on stem cell transplants and graft versus host disease (GVHD). A few points:

1) Types of stem cell transplant:
Autologous: Patient's own mononuclear cells are harvested from bone marrow or (now more commonly) from peripheral blood prior to high-dose myeloablative chemotherapy/radiotherapy. The cells are then reinfused during the period of prolonged bone marrow failure that occurs after these treatments in order to help restore hematopoiesis. Classically this type of transplant was used in lymphoma, but there is an ever-expanding list of trials for other indications including solid tumors and plasma-cell dyscrasias.

Allogeneic: Stem cells are harvested from the bone marrow of healthy donors or newborn umbilical cord/placenta. The cells are infused to reconstitute the patient's hematopoeitic system, but also can have direct anti-leukemia activity, termed graft-versus-leukemia (GVL). Given that the cells are from a donor, there are a greater number of risks than in autologous transplant due to immune suppression and graft-versus-host-disease (below).

2) Graft versus host disease:
Lymphocytes from the donor may target normal host tissues and cause inflammation, with particular predilection for skin, gut, liver, and lungs. The acute form usually occurs before 100 days post-transplant and can present with a maculopapular or bullous rash, cholestasis potentially leading to hepatic failure, or secretory diarrhea. The chronic form more resembles other autoimmune disorders, presenting with arthritis, scleroderma-like skin changes, sicca syndrome, chronic hepatitis, and GI malabsorbtion.

The risk of GVHD is directly related to age and inversely related to the the degree of major histocompatibility antigen matching between donor and recipient. It remains the major complication of allogeneic transplant, affecting upwards of 40% of patients.

Brugada syndrome

The answer to this morning's amuse-bouche was Brugada syndrome. More from an old blog post here: http://morningreporttgh.blogspot.com/2010/03/brugada-syndrome-and-arrhythmogenic-rv.html

Pericardial effusion

Morning report today was on pericardial effusions.

Here is a prior post on the causes of pericarditis
http://morningreporttgh.blogspot.com/2009/04/shot-through-heart-and-your-to-blameyou.html.
When thinking of pericardial effusions, the causes are all the same, as well as the addition of hypothyroidism.

We talked only briefly about cardiac tamponade, but here is a link to the JAMA rational clinical exam paper 'Does this patient have cardiac tamponade'
http://jama.ama-assn.org/content/297/16/1810.abstract

Blogging is so 2010

It's early July: the season of bad tan lines and new chief medical residents (in this case maybe both in one package...just you wait!)
I will be using the blog quite a bit this year, but I plan to use it a little differently than before in a few ways:

(1) I will try to post daily:

I want to spare your email inboxes, so I will post daily on this site, and you can check things out as you see fit for your own learning goals.

(2) I will not really be blogging:

The posts will usually be shorter, less like a true blog and more similar to twitter-style tweets, with links to papers or other resources (including prior blog posts from TGH, TWH, and MSH morning report blogs).

However, I will write longer posts on topics that haven't been covered before and can be reasonably covered in without too much text .

(3) I will also tweet:

For those of you who already have twitter or are interested in using it, I will tweet the same links as I blog @tghcmr (http://twitter.com/#!/search/tghcmr)

I am here to help you learn internal medicine this year, so if you find none of this works well for you, let me know, and I can always make changes.

Cheers,

Chris