The Clinical Problem Solvers

Episode description

Reza and Rabih talk through a case

RLR #4 – Transient loss of consciousness 
A 43-year-old man with a history of epilepsy, coronary artery disease, and pulmonary sarcoidosis presented after experiencing an unheralded transient loss of consciousness. His initial evaluation revealed no abnormalities. Ambulatory cardiac event monitoring demonstrated an episode of complete heart block, and myocardial perfusion imaging showed a focal perfusion defect in the left ventricle (thought to represent a prior myocardial infarction versus sarcoidosis). He underwent pacemaker and implanted cardiac defibrillator (ICD) placement and was discharged home.

Teaching Point:

• Small-cell lung cancer(SCLC) is a primary pulmonary malignancy of epithelial origin that most commonly occurs in older patients with long-standing smoking histories. Clinically, it typically presents aggressively with pulmonary symptoms (e.g., cough, dyspnea, hemoptysis), manifestations related to intra- or extra-thoracic spread, or with a variety of paraneoplastic syndromes (e.g., endocrine, dermatologic, neurologic). Prognosis is poor, with median survival without treatment being 2-4 months.
• Sarcoidosis is a multisystem granulomatous disease that most often affects the lungs, skin, and eyes.Cardiac manifestationsof sarcoidosis include arrhythmias, cardiomyopathy, sudden cardiac death, and, rarely, coronary artery vasculitis. Diagnosis can be made by endomyocardial biopsy or with compatible imaging findings (e.g., delayed gadolinium enhancement on cardiac MRI) or cardiac manifestations (e.g., complete heart block, ventricular arrhythmias, or otherwise unexplained heart failure) in a patient with known extra-cardiac sarcoidosis. 

Episode description

Reza and Rabih talk through a case

RLR #3 – Scrotal pain 
A 75-year-old man with a history of Alzheimers dementia presented with 2 weeks of bilateral scrotal pain. Genital exam was unremarkable. Chest radiography revealed a right lower lobe opacity and computed tomography of the abdomen was notable for diffuse retroperitoneal lymphadenopathy. Biopsy was performed of a mediastinal lymph node which revealed findings consistent with metastatic small-cell lung cancer.

Teaching Points:

• Acute scrotal pain is a common complaint encountered in the emergency department and can be caused by pathology within the scrotum, abdomen (i.e., inguinal hernia), or referred from the retroperitoneum. The most common causes of acute scrotal pain include torsion of the testicular appendage, epididymitis, and testicular torsion. The initial evaluation is focused on excluding the presence of testicular torsion (a surgical emergency) by exam and, often times, doppler ultrasonography. 

Student Dr. Dereck Paul, Dr. Utibe Essien and Dr. Kimberly Manning join the CPSolvers to discuss racial disparities. This all-star crew discusses the role of race and inequality in the current COVID-19 pandemic and medicine more broadly. Don’t miss out on this truly powerful episode. 

Student Dr. Dereck Paul

Dereck Paul is a 4th-year medical student at the University of California, San Francisco School of Medicine and applying into residency this fall. He studies the relationships between homelessness and health under Dr. Margot Kushel at the UCSF Center for Vulnerable Populations. He was a 2018 Student National Medical Association David E. Satcher MD, PhD Health Disparities Research Fellow for his work mapping the role of structural racism in susceptibility to housing insecurity and homelessness. Outside of his studies and research, he writes about health policy, medical education, and the underrepresented medical trainee experience.

Dr. Utibe Essien

Utibe Essien is an Assistant Professor of Medicine at the University of Pittsburgh and a health disparities researcher in the VA Center for Health Equity Research and Promotion. He completed Primary Care residency and General Internal Medicine fellowship at the Massachusetts General Hospital and Harvard Medical School. Dr. Essien’s research focuses on developing interventions to advance equity in the management of cardiovascular diseases.

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. Avital O’Glasser presents a clinical unknown on Virtual Morning Report to CPSolvers, Jack and Reza.

Case overview and teaching points

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Dr. Avital O’Glasser

Avital O’Glasser is an Associate Professor of Medicine at Oregon Health & Science University (OHSU) in the Division of Hospital Medicine. She is the medical director of OHSU’s hospitalist-led Pre-Operative Medicine Clinic, as well as The Curbsiders Kashlek Memorial Hospital Chief of Perioperative Medicine. She is also the Assistant Program Director for Social Media and Scholarship for OHSU’s Internal Medicine Residency Program. She has been a member of the OHSU faculty since completing her internal medicine residency training there, and she is a graduate of Jefferson Medical College. She enjoys spending time with her husband, two young boys, and labradoodle Matilda.

Case Summary

A 31-year-old man with no prior medical problems presented with subacute abdominal pain, recurrent fevers, and weight loss. His work-up was notable for stigmata of endocarditis, although bacterial blood cultures were persistently negative. Ultimately, he underwent aortic valve replacement, and pathologic examination of the valve tissue demonstrated coliform bacteria with molecular testing confirming a diagnosis of Streptobacillus moniliformis. Further history confirmed that he owned a pet rat and had experienced repeated bites prior to his illness. 

Teaching Points

• Streptobacillus moniliformisis a pleomorphic, gram-negative rod that is the predominant cause ofrat bite fever (RBF). This pathogen is found across the United States and is most commonly transmitted by rat bites, with numerous cases being acquired from pets or laboratory animals. Clinical manifestations include fever (potentially relapsing), arthralgias, and rash. Serious complications include infective endocarditis, meningitis, systemic vasculitis, and other organ involvement.

Episode description

Reza and Rabih talk through a case

RLR #2 – Hoarseness
A 54-year-old man with a history of PTSD, depression, and a recent diarrheal illness presented with acute dysphagia to liquids and solids. Neurologic exam was initially unremarkable, but the patient returned the next day with diplopia and ataxia. Exam was notable for new bilateral cranial nerve III palsies and areflexia. Laryngoscopy revealed unilateral vocal cord paralysis. Cerebrospinal fluid analysis was notable for elevated protein and positive GQ1b antibody testing. He was diagnosed with Miller Fisher’s syndrome, a variant of Guillain-Barre Syndrome.

Teaching Points:

• Miller Fisher’s Syndrome(MFS) is a rare variant of Guillain-Barre syndrome (acute inflammatory demyelinating polyneuropathy) that primarily affects the bulbar nerves. MFS is suggested by the classic triad of acute-onset ophthalmoplegia, ataxia, and areflexia and often occurs following a prodromal illness (upper respiratory infection or gastroenteritis). Diagnosis is supported by elevated cerebrospinal fluid protein as well as demonstration of GQ1b ganglioside autoantibodies (which are positive in 85% of cases). Prognosis is typically favorable, and most cases are self-limited. 

Episode description

Reza and Rabih talk through a case

RLR #1 – Lymphadenopathy
A woman in her 20’s with a history of prior possible thrombotic thrombocytopenic purpura (TTP) and recently treated secondary syphilis was transferred to a tertiary referral center for evaluation of generalized lymphadenopathy, new anemia, and thrombocytopenia. Laboratory workup was concerning for a Coombs-positive autoimmune hemolytic anemia, possible immune thrombocytopenia, and polyclonal gammopathy. Core and excisional lymph node biopsies were unrevealing for either infection or malignancy. Ultimately, anti-nuclear, anti-dsDNA, and anti-Sm autoantibodies were grossly positive and the patient was diagnosed with systemic lupus erythematosus.

Teaching Points:

• Systemic Lupus Erythematosus(SLE) is a complex autoimmune disease that most frequently presents with inflammatory arthritis, malar rash, and nephropathy.Hematologic abnormalities are common in SLE and are components of both the American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) diagnostic criteria. Common features include leukopenia (both neutropenia and lymphopenia), autoimmune hemolytic anemias (generally Coombs-positive, warm-type), and thrombocytopenia. SLE is a recognized cause of secondary thrombotic thrombocytopenic purpura (TTP), which may present concurrently with or, in some instances, precede the diagnosis of SLE.

Dr. Kushal Vaishnani presents a clinical unknown on Virtual Morning Report to student Dr. Jean-Claude Guidi and Dr. Ramya Ramachandran.

Case Overview & Teaching Points

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Problem Representation
A 53-year-old woman with a history of rheumatoid arthritis and amiodarone-induced lung injury on immunosuppression presented with acutely progressive hypoxic respiratory failure and hypotension, found to have a serpiginous truncal rash, acute anemia, and elevated beta-d-glucan.

Schemas
In this episode, we revisit the schemas for fever and rash (which highlights first addressing the life-threatening causes) and diffuse alveolar hemorrhage (which focuses on differentiating vasculitis from other etiologies).

Diagnosis
The patient underwent bronchoscopy with bronchoalveolar lavage fluid demonstrating elevated leukocytes with a neutrophilic predominance as well as progressively bloody fluid, consistent with diffuse alveolar hemorrhage. Silver stain was diagnostic for Pneumocystis jiroveci, and pathology revealed helminthic larvae consistent with Strongyloides stercoralis. The patient was diagnosed with both Pneumocystis pneumonia and Strongyloides hyperinfection syndrome!

Teaching Points:

• Beta-D-glucan(BDG) is a cell wall polysaccharide found in many fungal organisms (with notable exceptions including Cryptococcus, the zygomycetes, and Blastomyces dermatitidis) and is frequently used as a laboratory marker for invasive fungal infections. Caution is advised when interpreting this test, as it is imperfectly sensitive and false positives have been reported in association with certain hemodialysis filters, immunoglobulins (e.g., IVIG), albumin, and beta-lactam antimicrobials (thought to be more of an issue with older formulations). 
• Strongyloides stercoralisis an important human pathogen in tropical and subtropical areas throughout the world. While many cases of chronic strongyloidiasis are mild and may go unrecognized, severe manifestations can include the strongyloides hyperinfection syndrome and disseminated strongyloidiasis. Hyperinfection occurs when there is accelerated autoinfection (i.e., the ability to complete the parasitic life cycle entirely within the host – a trait relatively unique to Strongyloides among human helminthiases) and most commonly occurs in the setting of immune dysregulation or exogenous immunosuppression. 
• Pneumocystis jiroveciis an important opportunistic infection in immunosuppressed patients. Originally identified by Carlos Chagasin 1909, who believed it to represent a pulmonary manifestation of the parasite Trypanosoma cruzi, it was later reclassified as a fungus in 1988. The most frequent symptoms include subacute dyspnea, nonproductive cough, and low-grade fever, with hypoxemic respiratory failure being the most common manifestation of severe decompensation. 

Dr. Ruchit Rana presents a Human Dx unknown to Dr. André Mansoor and OHSU residents  – Drs. Logan Jones and Patricia Liu.

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Human Dx case

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Dr. Logan Jones

“Logan” Jones is a PGY-3 at OHSU in Portland, and will be joining the faculty as an assistant professor in the Division of Hospital Medicine with an academic focus on student assessment, curricular innovation, learner scholarship, clinical reasoning, and EMR proficiency. He is active in organized medicine with the American Medical Association and the American College of Physicians. Outside of medicine, he enjoys cooking with his sig fig Samantha, spending time on his yoga mat, and hiking throughout the Pacific Northwest.

Dr. Patricia Liu

Pat is currently one of the IM chief residents at Oregon Health & Science University. She will be a hospitalist next year and is interested in medical education, empowering women in medicine and improving care for inpatients with substance use disorders. In her free time, you can find her running, snowboarding and teaching tricks to her cat, Pekoe.

Dr. Ruchit Rana

Ruchit Rana is currently a second-year internal medicine resident at Baylor College of Medicine. He completed medical school at Baylor College of Medicine. He has a passion for practicing and improving medical education at all levels. In his free time, he enjoys cooking and baking dishes across all ethnicities and maintaining his multiple freshwater aquariums at home.

Dr. André Mansoor

André Mansoor is an Assistant Professor of Medicine at Oregon Health and Science University in Portland, Oregon. His favorite book is the Count of Monte Cristo and his favorite band is Stone Temple Pilots. He is the author of an internal medicine textbook called Frameworks for Internal Medicine. https://www.amazon.com/Frameworks-Internal-Medicine-Andre-Mansoor/dp/1496359305. 

Case Summary

A 70-year-old man presented with six months of dyspnea on exertion, night sweats, and weight loss. He was found to be febrile and in distributive shock, with laboratory analysis demonstrating cytopenias, coagulopathy, and lactic acidosis. Computed tomography of the abdomen and pelvis was notable for hepatosplenomegaly, and a bone marrow biopsy revealed a monoclonal B-cell population with hemophagocytosis. The patient was diagnosed with diffuse large B-cell lymphoma complicated by hemophagocytic lymphohistiocytosis (HLH).

Teaching Points:

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, immune-mediated disease caused by impaired NK and cytotoxic T-cell function. While genetic defects play a prominent role in triggering HLH in children, most cases of HLH in adults are secondary to another disorder, such as infections (e.g., EBV, histoplasmosis), hematologic malignancies (e.g., NK, T, or B-cell lymphomas), or autoimmune disease (e.g., systemic lupus erythematosis). 

Dr. Anand Patel presents a Human Dx unknown to Rabih and Indiana residents  – Drs. Devika Gandhi and Cody Hill.

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Human Dx case

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Dr. Devika Gandhi

Devika Gandhi is a second-year internal medicine resident at Indiana University. She is originally from Dayton, Ohio and received her undergraduate degree from the University of Akron. She earned her medics degree from Northeast Ohio Medical University in Rootstown, Ohio (Go Walking Whales!). After residency, she plans to pursue a career in gastroenterology/hepatology. During her free time, she enjoys reading, cooking, and going out to trivia with friends.

Dr. Cody Hill

Cody Hill is a second-year Med-Peds resident at Indiana University. He attended Clemson University for his undergraduate/graduate studies and the University of South Carolina School of Medicine Greenville for medical school. Although he loves taking care of patients, his true passion lies in medical education, especially when it relates to clinical reasoning and evidence-based medicine. He is also very invested in resident wellness and mentorship, which led him and a fellow classmate to start their own podcast called The Resident Lounge (@resident_lounge). After residency, he plans to pursue a career as a Med-Peds hospitalist and a medical educator with the ultimate goal of one day becoming a program director. Cody also just became a father, so in addition to taking care of his newborn daughter, he and his wife enjoy walking their dog, gardening, cooking and exploring Indianapolis for new craft beers.

Dr. Anand Patel

Dr. Anand Patel is a hematology-oncology fellow at the University of Chicago and the Medical Education Lead at the Human Diagnosis Project. He attended University of Missouri-Columbia for medical school and completed both his internal medicine residency and chief residency at Northwestern. Anand’s academic interests include medical education and clinical reasoning. Specifically within hematology-oncology, he is interested in clinical trial design using targeted therapies for patients with leukemias and myeloid neoplasms.

Case Summary

An 83-year-old woman with acute myeloid leukemia and psoriasis (on immunosuppression) presented with six weeks of fatigue, weight loss, and a dry cough. Her medical history was notable for two indeterminate interferon-gamma release assays. Computed tomography of the chest demonstrated a 3 x 3 cm right lower lobe mass, with subsequent biopsy revealing necrotizing granulomas and acid-fast bacilli. Cultures ultimately grew Mycobacterium avium complex (MAC).  

Teaching Points:

Mycobacterium avium complex (MAC) is a ubiquitous water and soil-based organism. Clinical manifestations include pulmonary infections, lymphadenitis, and disseminated disease in severely immunocompromised patients (e.g., those with HIV and CD4 counts < 50 cells/µL). Pulmonary manifestations of MAC include cavitary upper lobe disease similar to tuberculosis, fibronodular bronchiectasis that often develops in the right middle lobe or lingula, solitary pulmonary nodules, and hypersensitivity pneumonitis. 

Dr. Anand Jagannath presents a Human Dx unknown to Reza and U of C residents – Drs. Alec and Austin Rezigh.

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Human Dx case

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Dr. Alec Rezigh

Alec Rezigh is a third-year internal medicine resident at The University of Colorado. He is originally from Houston, TX and received his undergraduate degree at the University of Texas at Austin. He then went back to Houston for medical school at the University of Texas at Houston (McGovern) Medical School. In his free time, he loves all things basketball, traveling with his wife, and napping on the couch with his dog. Following completion of his training, he will return to Houston to be an academic hospitalist. He wishes to thank Dr. Juan Lessing for his amazing mentorship and inspiring his interest in clinical reasoning – and introducing him to Rabih and Reza!

Dr. Austin Rezigh

Austin Rezigh is a third-year internal medicine, primary care track resident at the University of Colorado. He completed medical school at UT Southwestern and is excited to pursue a career in academic general internal medicine. In his free time, he enjoys trying new cuisines, exercising, and spending time with his fur-niece, Kensie.

Dr. Anand Jagannath

Dr. Anand Jagannath is a clinician-educator at the University of California, San Diego (UCSD) and hospitalist at the VA San Diego. He completed medical school at the Tufts University School of Medicine and internal medicine residency and chief residency at Albert Einstein College of Medicine/Montefiore Medical Center. At UCSD, Anand’s interests include bedside team rounding, teaching clinical reasoning to medical students and residents, learning from his learners, and promoting a safe and inclusive learning environment. He is also a Section Editor for adult medicine cases at the Human Diagnosis Project. When he’s not getting excited about medicine, you’ll probably find Anand cooking food, watching shows about food on Netflix, running, or playing basketball or his violin.

Human Dx Case Summary

A 66-year-old man with alcohol use disorder and chronic NSAID use presented with one day of abdominal pain and nausea. Laboratory analysis was notable for hypercalcemia to 16 mg/dL (with low parathyroid hormone and vitamin-D levels), metabolic alkalosis, and an acute kidney injury. The patient disclosed that he had recently consumed large amounts of calcium carbonate for his abdominal pain, and he was diagnosed with the milk alkali syndrome. His serum calcium normalized after receiving intravenous fluids and withholding further calcium supplementation.

Teaching Points:

The milk alkali syndrome, the third most common cause of hospital admission for hypercalcemia, develops from excess consumption of calcium supplements (e.g., calcium carbonate). Patients classically present with hypercalcemia, metabolic alkalosis, and renal insufficiency. The metabolic alkalosis is thought to be due to hypercalcemia-induced nephrogenic diabetes insipidus, while renal insufficiency develops as a result of calcium-induced renal tubular damage and vasoconstriction of the renal afferent arteriole. Treatment includes intravenous fluid resuscitation and cessation of calcium supplementation.