Monday, September 19, 2011

Non-resolving pneumonia

Today in morning report was a great case of non-resolving pneumonia. For more, see a prior post here.

See the IDSA guidelines here, and skip to recommendation #38 to read about the work-up of a pneumonia that fails to respond to therapy.

Friday, September 16, 2011

Levamisole toxicity

Today's amuse-bouche was a case of a levamisole-related cutaneous vasculitis syndrome. A few quick points: 

  • Recent trend in cocaine being adulterated by levamisole, 
    • An anti-helminth agent in the 1960s first identified as a cocaine adulterant in the USA in 2003 
    •  Now found in majority of cocaine seized at US borders, common in Canada also
    • Proposed that levamisole potentiates the psychotropic effects of cocaine, and that producers intentionally add it during the cocaine manufacturing process 
  • Associated with a cutaneous vasculitic syndrome 
    • Purpuric lesions and/or cutaneous necrosis 
    • Involves the ears in ~50% of reported cases 
    • Lab associations: neutropenia + pANCA and + cANCA
More in a case-series review here.


Today in MR we had a case of hyponatremia. See a prior post here with links to a few good review papers.

Neurologic presentations of HIV infection

Last week in morning report was an excellent case of ptosis and diplopia in a patient with HIV infection. This is a big topic, but a few points about neurologic involvement in HIV:

1) Acute seroconversion reactions: 

-Although rare, acute neurologic presentations at the time of HIV infection do occur, including aseptic meningitis, Bell's palsy, and inflammatory neuropathies. CSF testing for HIV may be positive in these patients.

2) Opportunistic infections: A variety of OI can manifest with neurologic presentations:

- Progressive Multifocal Leukoencephalopathy (PML): a demylenating CNS disease caused by JC virus, mostly in patients with CD4 counts less than 100. Usual presentation is a subacute deterioration in mental status with possible focal neurologic signs/symptoms, with fever and headache not usually present.

- Cytomegalovirus (CMV): although 60% of the population have evidence of exposure to CMV, patients with HIV and CD4 counts less than 50 and other immunocompromised states are at risk of clinical disease from reactivation. CMV can infect and reactivate throughout almost the entire spectrum of the CNS and PNS- from the brain to peripheral nerves. For this reason, the neurologic presentation can be any combination of encephalitis, ventriculitis, myelitis, gangionitis and peripheral polyneuropathy. 

- Cryptococcus neoformans: an encapsulated yeast found throughout the world. It usually is cleared by the immune system, but in immunocompromised patients, including HIV patients with CD4 counts less than 100, it can remain in a latent state that can disseminate to organs, with the CNS being particularly common. The usual presentation is that of a subacute menigoencephalitis, with fever, headache and malaise. It can also present with complications of increased ICP, including seizure.

- Toxoplasma gondii: intracellular protazoan with high seroprevalence in the population, with most primary infections being asymptomatic or flu-like. Reactivation can occur in immuno compromised hosts, usually in patients with HIV and CD4 counts less than 200. Usually casues an encephalitis and presents with fever, headache, and focal neurologic signs or seizures. 

3) Neoplasms: primary CNS lymphoma is usually a high grade B-cell lymphoma and almost always related to Epsetin -Barr Virus (EBV). It usually presents in HIV patients with CD4 counts less than 100 with headache, changed mental status, focal neurologic signs or seizures. 

4) Immune reconstitution inflammatory syndromes (IRIS): a group of syndromes casued by the inflammation generated by a reconstituted immune system in the first 4-8 weeks after starting on combined antiretroviral therapy. Usually seen in HIV patients with CD4 counts less than 50 being started on therapy for the first time in the setting of an opportunistic infection. Typically presents as a paradoxical worsening of course in patients with HIV encephalitis, cryptococcal meningitis  toxoplamsamosis encephalitis and PML.

5) HIV associated peripheral neuropathies: many peripheral neuropathic syndromes have been reported in the context of HIV infection, with the most common being a distal peripheral sensory neuropathy. Modifiable risk factors include use of neurotoxic medications, diabetes and alcohol abuse.

6) HIV-associated vacuolar myelopathy: an entity of unclear pathophysiology affecting the spinal cord neurons, more often the dorsal column. It presents with often initial errectile dysfunction and hyper-refexia, but progresses to asymmetric spastic leg weakness, dorsal column vibration/position sensory loss, and ataxic gait.

7) HIV Associated neurocognitive disorders (HAND): this is a group of neurocognitive changes thought to be a spectrum of a subcortical process that primarily affects attention/concentration, psychomotor speed, memory/learning, information processing, and executive function, while language and visuospatial abilities are often relatively unaffected.

More on diagnosis of these conditions from a review article here.

Tuesday, September 13, 2011

Elevated liver enzymes

Today in MR was a case of elevated liver enzymes. See here for a previous post on the topic.

Friday, September 9, 2011

Weekly Amuse-Bouche Links

For more on this week's amuse-bouche topics see the following links:

- Pendred's syndrome here
- Dermatologic findings in dermatomyositis here
- Familial Adenomatous Polyposis here
- Limb lead reversal here

Thursday, September 8, 2011

Hyperkalemia and Renal Tubular Acidosis

We had a great case of hyperkalemia in MR, likely due to an underlying type IV renal tubular acidosis in the setting of diabetes.

A prior post on hyperkalemia here, with a link at the bottom to a recent CMAJ article on management.

A prior post on renal tubular acidosis here, with a good review from the Archives here.

Thursday, September 1, 2011


Morning report today was a case of hypercalcemia. More from a prior post here.

Medullary Thyroid Cancer

Yesterday in morning report we had a really interesting case of medullary thyroid cancer presenting with chronic diarrhea and complicated by heart failure, likely secondary to amyloidosis.

A little more about medullary thyroid cancer (MTC):

- MTC can be either sporadic or inherited. Inherited forms involve mutations to the RET proto-oncogene and can be either be alone or as part of one of the Multiple Endocrine Neoplasia syndromes- MEN 2A or MEN 2B.

- MEN 2A is characterized by MTC with hyperparathyroidism and/or pheochromocytoma

- MEN 2B is characterized by MTC with typical phenotyic features such as marfanoid body habitus or mucosal neuromas with or without pheochromocytoma.

- Most patients present with a thyroid mass, but some present with symptoms of local spread such as dysphagia, dyspnea, or hoarseness. Roughly 10% will present with systemic symptoms related to the production of neuroendocrine mediators such as calcitonin, resulting in bone pain, flushing, and/or diarrhea.

- Those that present with systemic symptoms usually have metastatic disease.

- More in a review from Cancer here

We also found out through our group searching excercise that MTC is associated with secondary amyloidosis casued by calcitonin.

-A good related article sent out by Dr. Abrams here.

- More on amyloidosis from a prior post here.