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Episode description

Drs. Kimberly Manning and Gurpreet Dhaliwal discuss an unknown case as part of the 50th CPSolvers Virtual Morning Report.

Virtual Morning Report

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Dr. Kimberly Manning

Kimberly D. Manning, MD is a general internist/hospitalist who serves as Associate Vice Chair of Diversity, Equity, and Inclusion for the Department of Medicine at Emory University School of Medicine. Manning was recently promoted to Professor of Medicine and additionally serves as residency program director for the Transitional Year Residency Program at Emory. She has a strong commitment to supporting underrepresented minorities in medicine, serving underserved populations, and creating better understanding of our patients and each other through storytelling and narrative medicine. A huge fan of the CP Solvers, Dr Manning is as enthusiastic about being a teacher as she is being a lifelong learner. 

Dr. Gurpreet Dhaliwal

Dr. Dhaliwal is a clinician-educator and Professor of Medicine at the University of California, San Francisco. He is the site director of the internal medicine clerkship at the San Francisco VA Medical Center, where he teaches medical students and residents in the emergency department, urgent care clinic, inpatient wards, outpatient clinic, and morning report. His academic interests are the cognitive processes underlying diagnostic reasoning and clinical problem-solving and the study of diagnostic expertise. Dr. Dhaliwal enjoys playing pickup basketball with his two sons … even though both can handily defeat him

Case Summary

A 69-year-old man with a history of prior cerebrovascular accident (CVA) presented with acute onset right leg weakness and paresthesias. Laboratory analysis was notable for elevated inflammatory markers. A magnetic resonance image of the brain showed a ring-enhancing lesion in the left parietal lobe, with fine needle aspiration revealing gram positive cocci in chains. Cultures grew Streptococcus intermedius (a member of the S. anginosusgroup), and the patient was diagnosed with a bacterial brain abscess.

Teaching Points:

• Brain abscesses can be caused by bacteria, fungi, and parasites. Bacterial brain abscesses can arise via contiguous spread of bacteria from head and neck sources or by hematogenous routes. The causative organism often varies with the underlying immune status of the host. Among immunocompetent hosts, the most common organisms are Staphylococcusand Streptococcus spp (e.g., S anginosus). Neurosurgical sampling may be required to identify the pathogen and achieve source control.
• Lacunar infarctions are an important form of ischemic strokes (representing ~20%) caused by cerebral small vessel disease. Pathophysiologically, the most important risk factor is uncontrolled hypertension, which can lead to small vessel injury and subsequent occlusion. Most lacunar strokes involve the basal ganglia, pons, and subcortical white matter structures (e.g., internal capsule). While many clinical syndromes have been described, the 5 most common include pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, and dysarthria-clumsy hand syndrome.