NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on Thursday in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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May 23, 2023
MKSAP 18 General Internal Medicine, Question 131
Stem:
A 47-year-old man is evaluated for a 2-day history of cough productive of small amounts of yellow sputum, as well as sinus congestion, frontal headache, rhinorrhea, and malaise. He has had no fevers, chest pain, or shortness of breath. Medical history is otherwise unremarkable.
On physical examination, vital signs are normal. There is tenderness over the maxillary sinuses bilaterally. The nasal mucosa is diffusely edematous with moderate amounts of clear discharge. Pharyngeal examination reveals erythema without tonsillar exudate. The tympanic membranes appear normal. No cervical lymphadenopathy is noted. The remainder of the examination is normal.
Which of the following is the most appropriate treatment?
Responses Received from Members (1,105 Responses):
The Correct Answer is: D. Intranasal fluticasone
Educational Objective
Treat cough due to acute rhinosinusitis.
Critique
This patient with acute cough due to acute rhinosinusitis should be treated with an intranasal glucocorticoid, such as fluticasone. Most upper respiratory tract infections (URIs) are caused by viral infections and resolve spontaneously within a few days. Patients without clear evidence of bacterial infection should be treated symptomatically. A meta-analysis of patients with acute rhinosinusitis found that use of intranasal glucocorticoids increased the rate of symptom response compared with placebo; there was a dose-response curve, with higher doses offering greater relief. Analgesics, such as NSAIDs and acetaminophen, may relieve pain. Only limited evidence supports saline irrigation in the relief of nasal symptoms; careful attention should be paid to the use of sterile or bottled water. Instructions for nasal saline irrigation are available online (www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375.htm). First-generation antihistamines may help dry nasal secretions; however, evidence supporting their efficacy is lacking, and sedation is a common side effect. Decongestants are of possible benefit in patients with evidence of eustachian tube dysfunction but should be used with caution in elderly patients and those with cardiovascular disease, hypertension, angleclosure glaucoma, or bladder neck obstruction. Antitussive agents are generally ineffective.
Empiric treatment of URI symptoms with antibiotics (such as amoxicillin) is ineffective, increases bacterial antibiotic resistance, and may cause multiple adverse effects, including Clostridium difficile colitis. Antibiotics should be reserved for patients with symptoms lasting more than 10 days, worsening symptoms after initially improving viral illness, or severe symptoms or signs of high fever (>39 °C [102.2 °F]) with purulent nasal discharge or facial pain for at least 3 consecutive days.
A systematic review concluded that centrally acting (codeine, dextromethorphan) or peripherally acting (moguisteine) antitussive therapy results in little improvement in acute cough and is not recommended.
Inhaled albuterol is indicated for patients with evidence of wheezing, which this patient does not have. For patients who develop postinfectious airway hyperreactivity with a subacute or chronic cough, albuterol and other asthma therapies are beneficial.
Key Points
Acute rhinosinusitis may be treated symptomatically with analgesics and intranasal glucocorticoids; antibiotics are not recommended without clearly established bacterial infection.
Bibliography
Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164:425-34. PMID: 26785402
Copyright 2018, American College of Physicians.
May 9, 2023
MKSAP 19 Pulmonary/Critical Care Medicine, Question 24
Stem:
A 50-year-old man is referred for poorly controlled asthma. Triggers include exercise and exposure to dust, pollen, and fumes. He has allergic rhinitis. He has been treated with several courses of glucocorticoids, but symptoms recurred after he stopped treatment despite regular use of his fluticasone-salmeterol and tiotropium inhalers. His only other medication is albuterol. He has good inhaler technique.
On physical examination, vital signs are normal. BMI is 23. Pulmonary examination reveals few expiratory wheezes. The remainder of the examination is unremarkable.
Laboratory studies reveal a normal total IgE level and complete blood count.
Chest radiograph is normal. Spirometry demonstrates moderate airflow obstruction that improves with bronchodilators.
Which of the following is the most appropriate diagnostic test to perform next?
Responses Received from Members (864 Member Responses):
The Correct Answer is: A. Absolute blood eosinophil count
Educational Objective
Diagnose allergic asthma phenotype.
Critique
The most appropriate diagnostic test for this patient is measurement of the absolute blood eosinophil count (Option A). The patient presents with symptoms suggestive of allergic asthma; establishing this asthma phenotype can help direct therapy. Clinical characteristics suggesting a type 2 asthma phenotype include atopy, seasonal exacerbations, hay fever, and allergen sensitization. Biomarker evaluation in these patients often demonstrates serum or sputum eosinophilia and/or high IgE levels. This patient has a normal IgE level, but this does not preclude type 2 asthma. Obtaining a blood absolute eosinophil count will help establish the phenotype. In patients with severe disease, elevated levels of IgE and eosinophils are therapeutic targets for biologic therapies. Several types of biologic therapies are available that are directed against type 2 inflammation, targeting pathways involved in activation of eosinophils and IgE production. Use of antibody therapies in eligible patients with severe persistent allergic asthma despite standard therapy reduces symptoms, exacerbations, and need for oral glucocorticoids.
An α1-antitrypsin level (Option B) should be obtained once in all patients with chronic obstructive pulmonary disease. A pattern of basilar emphysema, associated liver disease or panniculitis, or a strong family history of emphysema in patients with COPD suggests possible α-1 antitrypsin deficiency, but none of these features is sufficiently sensitive for the condition. Routine testing is not indicated in patients with asthma.
Patients with allergic bronchopulmonary aspergillosis (ABPA) present with difficult-to-control asthma, productive cough, and expectoration of mucus plugs. Commonly accepted diagnostic criteria include elevated IgE levels, positive skin tests to Aspergillus antigens, increased Aspergillus-specific IgE and IgG levels, and either central bronchiectasis or infiltrates. This patient does not have the clinical phenotype of ABPA, radiographic findings, or elevated IgE level suggesting ABPA. Measuring Aspergillus-specific IgE level (Option C) is not indicated.
Identifying the presence of atopy can identify an allergic asthma phenotype in a patient with respiratory symptoms. Atopic status can be measured by skin prick testing or measurement of allergen-specific IgE testing (Option D). Skin prick testing is rapid, simple, and relatively inexpensive. Measurement of immunoglobulin-specific IgE is more expensive but not more accurate. However, the first management step for this patient is to measure the total blood eosinophil count to determine his asthma phenotype.
Key Points
Clinical characteristics suggesting a type 2 asthma phenotype include atopy, seasonal exacerbations, hay fever, and allergen sensitization.
For patients with symptoms suggestive of type 2 asthma phenotype, measurement of IgE levels and total eosinophil count can be used to confirm this asthma phenotype and direct therapy.
Bibliography
McGregor MC, Krings JG, Nair P, et al. Role of biologics in asthma. Am J Respir Crit Care Med. 2019;199:433-445. PMID: 30525902 doi:10.1164/rccm.201810-1944CI
Copyright 2019, American College of Physicians.