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September 29, 2020

Question Recap:  A 40-year-old man with HIV infection is brought by his wife to the emergency department. He is experiencing fever, headache, stiff neck, photophobia, and nausea. His symptoms started 12 hours ago. His blood pressure is 110/80 mmHg, pulse 100/min, respiratory rate 18/min, temperature 103F. The lungs are clear. There are no heart murmurs or jugular venous distention. The neurological exam is normal.

Laboratory results include: hemoglobin 11 g/dL, hematocrit 40%, platelets 130,000/cc, leukocytes 17,000/cc, creatinine 0.9 mg/dL, blood glucose 100 mg/dL, CD4 180/cc, HIV RNA 1,125,000 copies/mL.

Lumbar puncture is obtained and analysis shows: glucose 35 mg/dL, protein 135 mg/dL, leukocytes 1,200/cc (80% neutrophils). Blood is drawn for culture. Ceftriaxone, vancomycin and dexamethasone are started. Antiretroviral therapy is started. Blood culture is now available and shown below.

What is the best treatment?

Responses Received from Members (416 Total):

 

 

 


Correct Response is:  C. Add ampicillin

Question Explanation:  The most likely diagnosis in this case is bacterial meningitis.

Empiric broad spectrum antibiotics with vancomycin plus cefepime or ceftriaxone and steroids are used when blood cultures are unavailable. While streptococcus is the most common cause of bacterial meningitis, ampicillin is added to persons with increased risk for listeria infection, such as elderly, neonates, and immunocompromised patients. Once the blood cultures are available, narrowing down the spectrum as much as possible is the best course of action.

In this case, the patient is not immunocompetent given his low CD4 count (AIDS). Additionally, the blood culture in this case shows Gram-positive rods consistent with Listeria monocytogenes infection, which is inherently resistant to cephalosporins. Listeria is sensitive to ampicillin monotherapy, and vancomycin is not needed. Acyclovir is kinase inhibitor used in the treatment of HSV encephalitis, not bacterial meningitis.

Antibiotic prophylaxis with rifampin for persons in close contact with a Neisseria meningitis patient should be started within 24 hours of the patient’s diagnosis regardless of the contact’s meningococcal vaccination status.


September 22, 2020

Question Recap:  A 39-year-old woman from Connecticut presents to the emergency room with fever, malaise, rhinorrhea, cough, and bilateral eye redness. The symptoms started three days ago. When she woke up this morning, she noticed a red rash on her neck, back, shoulders, chest, and arms. Her medical history is unremarkable and she received all childhood vaccinations. She is sexually active with her long-term boyfriend. She works as a flight attendant and was in Israel and Spain one week ago.

What is the best next step in the management of this patient?

Responses Received from Members (429 Total):

 

 


 

Correct Response is:  C. Airborne Isolation

Question Explanation:  The most likely diagnosis in this case is measles. Israel and Western Europe have measles epidemics, and individuals returning from endemic areas with symptoms of illness should be tested for the infection. One dose of MMR vaccine is 93% effective against measles, and the recommended two doses is 97% effective against measles. However, immunity from vaccination wanes with time, and most individuals require a booster dose before traveling to endemic areas.

Patients with suspected measles should be placed under airborne isolation because measles is very contagious. Serum and nasopharyngeal swabs are used to test for measles PCR. Treatment is supportive (no specific antiviral therapy).

CSF FTA is the most sensitive test for neurosyphilis. While neurosyphilis can occur at any stage of syphilis infection, this patient has no signs or symptoms of syphilis infection, such as painless chancre or palmar erythema.

HAV is transmitted via the oral-fecal route and associated with gastrointestinal symptoms like diarrhea and vomiting, none of which are present in this patient. Among HAV infected patents, the HAV vaccine is used for post-exposure prophylaxis.

While this patient lives in the northeastern U.S. where Lyme disease is endemic, she has nothing in her history to suggest Borrelia infection (hiking, tick bite, erythema migrans or target rash).

This patient is most likely infected with Rubeola virus causing measles, and she will eventually need analgesics and fluid replacement therapy. Regardless, the most important step is to isolate the patient.


September 15, 2020

Question Recap:  A 69-year-old man presents to the emergency department with facial weakness and slurred speech. His symptoms started 45 minutes ago. His past medical history is significant for hypertension and diabetes mellitus. He used to smoke one pack of cigarettes per day for 50 years, but he quit two years ago. His blood pressure is 170/100 mmHg. Head CT with contrast shows no signs of bleeding.

Which of the following should be done before administering tPA?

Responses Received from Members (513 Total):

 

 

 


 

Correct Response is:  C. Finger stick glucose level

Question Explanation:  The only immediate laboratory result needed before administering a thrombolytic to an ischemic stroke patient is blood glucose level. This is because severe hypoglycemia can result in neuronal injury and mimic a stroke. In this case, giving a thrombolytic will increase the risk of bleeding without adding any benefit.

CT angiography of the head and neck is necessary if mechanical thrombectomy will be used (if the patient presents after 3-4.5 hours but less than 24 hours after the onset of symptoms). CT angiography is unnecessary in patients receiving tPA.

Coagulation labs (PT, aPTT, INR) and CBC are all part of the general evaluation of stroke patients but should never delay the administration of life-saving tPA.

Stroke patients who will not receive thrombolytic therapy are permitted to have permissive hypertension to maintain perfusion pressure unless the patient has coronary artery disease, congestive heart failure, atrial fibrillation, aortic dissection or preeclampsia/eclampsia, or if the systolic BP is greater than 220 mmHg or diastolic BP is more than 120 mmHg. In such cases, drugs such as hydralazine, enalaprilat, or labetalol are used to lower BP by no more than 15-20% within the first 24 hours of presentation.

Stroke patients who will receive thrombolytic therapy and have BP greater than 185/110 mmHg should be treated with an antihypertensive drug before administration of tPA to bring down the BP to 185/110 or less. This patient’s BP is 170/100 mmHg, and he is therefore not a candidate for hydralazine.


September 8, 2020

Question Recap:  A 19-year-old male presents to the emergency department with chest tightness, itching, headache, and abdominal pain. He was stung by a bee while working in his backyard 30 minutes ago. His blood pressure is 100/60 mmHg, pulse 80/min, respiratory rate 35/min, oxygen saturation 95% (ambient air), and temperature 98F. He takes tenofovir disoproxil plus emtricitabine for HIV pre-exposure prophylaxis and uses a salmeterol/fluticasone inhaler for asthma. Upon physical examination, there is mild abdominal tenderness and increased bowel sounds, but there is no wheezing, and the patient is not utilizing his accessory muscles to breathe.

What is the best next step in the management of this patient?

Responses Received from Members (429 Total):

 

 

 

 

 


Correct Response is:  B.  IM epinephrine

Question Explanation:  The most likely diagnosis in this case is anaphylaxis. Anaphylaxis is a severe and often life-threatening allergic reaction characterized by wheezing, pruritus, flushing, urticaria, hypotension, and angioedema that can compromise respiration. However, in some cases, early symptoms of anaphylaxis may appear subtly, especially among persons who are taking anti-inflammatory medications chronically. This patient is on fluticasone and presented within minutes of being stung. IM epinephrine is the first line therapy for anaphylaxis.

Steroids such as methylprednisone are potent anti-inflammatory drugs, but the onset of action is delayed for 4-6 hours. However, a short course of steroid is often used after the patient is stabilized to alleviate residual inflammation of anaphylaxis.

Antihistamine drugs like diphenhydramine will alleviate dermatologic manifestations of allergic reactions but will not address the cardiorespiratory failure associated with anaphylaxis.

Icatibant is a selective bradykinin receptor antagonist used in the treatment of acute hereditary angioedema, not anaphylaxis due to an allergic reaction.

Inhaled albuterol is effective in dilating the bronchi. However, it is a selective beta-2 adrenergic receptor agonist and will not address the hypotension and circulatory collapse associated with anaphylaxis. Epinephrine is needed to address systemic effects.


September 1, 2020

Question Recap:  A 28-year-old woman is brought to the emergency department by her husband. She had a tonic-clonic seizure that was followed by a period of confusion and disorientation. She has never before experienced a seizure and is in generally good health. She is up to date with all age-appropriate vaccines. In the emergency room, the neurological examination is normal and her vitals are within normal range. Brain MRI is obtained and shown below.

Neurosurgery is scheduled. Which of the following should be prescribed?

Responses Received from Members (486 Total):

 

 

 

 

Correct Response is:  D. Lamotrigine

Question Explanation:  The MRI shows a mass which provoked this patient’s single complex seizure. Most seizures are not treated at the first episode; however, this patient has a brain lesion. She is at high risk for recurrent seizure episodes; thus, pharmacotherapy should be started. Seizures are treated at the first episode if there is a focus causing the seizure that you cannot fix.

If there is no focus, no significant family history, a normal EEG, and the patient did not come in status epilepticus, do not give lifelong antiepileptic therapy after only a single seizure. Because she is of child-bearing age, the least teratogenic drug should be prescribed. Among all anti-epileptic drugs, lamotrigine and levetiracetam are the least teratogenic.

Valproic acid and phenytoin are highly teratogenic and should be avoided. Lorazepam is a benzodiazepine used in status epilepticus, but not chronically. With the exception of ethosuximide, all the other drugs are “broad acting” which means they are efficacious in partial or complex generalized seizures.

Ethosuximide is the drug of choice in absence seizures.


August 24, 2020

Question Recap:  The Board Review Question paused this week in order to gather information from members regarding what they need to know about COVID-19 for this fall.


August 17, 2020

Question Recap:  A 47-year-old man presents to clinic with fatigue and generalized weakness. The symptoms began one week ago. His medical history is significant for hypertension and tonic-clonic seizure disorder for which he takes chlorthalidone and valproic acid, respectively. His last epileptic episode was four years ago. He was diagnosed with HIV infection six weeks ago and prescribed elvitegravir/cobicistat, tenofovir alafenamide, and emtricitabine. His BMI is 29. 

His blood pressure is 130/90 mmHg, pulse 73/min, respiratory rate 13/min, and temperature 98F. Upon physical examination, there is no hepatosplenomegaly. He appears to be lethargic but is oriented to place and time. Laboratory results show: hemoglobin 12 g/dL, hematocrit 40%, leukocytes 8,500/cc, platelets 140,000/mm, sodium 140 mEq/L, potassium 4.1 mEq/L, chloride 105 mEq/L, creatinine 0.9 mg/dL, calcium 9.5 mg/dL, INR 1.0, AST 25 U/L, ALT 19 U/L, HIV RNA undetectable, HCV Ab negative, HBsAg negative, HBcAb negative, HBsAb positive, HAV IgM/IgG negative.

What is the best next step in the management?

Responses Received from Members (421 Total):

 

 

 

 

 

Correct Response is:  C. Obtain ammonia level

Question Explanation:  The correct answer is:  obtain ammonia level.  The most likely diagnosis in this case is valproic acid induced encephalopathy due to hyperammonemia. The likely mechanism of valproic acid toxicity is drug interaction. Cobicistat is a powerful CYP450 inhibitor that reduces the metabolism of valproic acid, upping its concentration in blood.

All patients on valproic acid who present with signs and symptoms of encephalopathy should have their ammonia level checked because valproic acid concentration does not correlate with the degree of encephalopathy and hepatic enzymes can also be normal in the setting of encephalopathy. Valproic acid should be discontinued and the antiretroviral therapy should be switched to an unboosted integrase inhibitor-based regimen  such as bictegravir/tenofovir alafenamide/emtricitabine.

Head CT without contrast is crucial in evaluating ischemic stroke. This patient has no signs or symptoms of stroke.

Lumbar puncture is used to diagnose bacterial meningitis. This patient has no signs or symptoms of CNS infection.

While acute HCV infection (antibody negative but RNA detected) from anal sex is possible among men who have sex with men especially if they are HIV co-infected, this patient’s liver enzymes are within normal range. Acute HCV infection almost always causes significant elevations in ALT and AST.

This patient has an established diagnosis of tonic-clonic seizures that is well controlled with valproic acid. EEG will not provide any diagnostic information in this encephalopathy case.

Asymptomatic hyperammonemia should NOT be treated even in the setting of cirrhosis.


August 11, 2020

Question Recap:  A 35-year-old man presents to the emergency department with shortness of breath that started two weeks ago. He has asthma and nasal polyps. He routinely uses a fluticasone/salmeterol inhaler with albuterol as needed. He started taking naproxen and hydrocodone-ibuprofen because he was involved in a motor vehicle accident a few days ago. He has been using his albuterol rescue inhaler more than twice daily for the past seven days. Upon physical examination, there is rhinorrhea, conjunctival erythema and facial swelling. His blood pressure is 130/100 mmHg, pulse 110/min, and respiratory rate 25/min. Oxygen saturation is 95% on 2 liters nasal cannula. CBC is normal. EKG shows sinus tachycardia. Methylprednisone and albuterol were administered and the symptoms improve. Which of the following is most likely to be beneficial in this case?

Responses Received from Members (466 Total):

Aug 11 answer graph

 

 

 

Correct Response is:  D.  Zileuton

Question Explanation:  The most likely diagnosis in this case is NSAID exacerbated respiratory disease. The triad of nasal polyps, asthma, and rhinosinusitis is characteristic. 1 in 5 adults with asthma will be sensitive to NSAIDs such as aspirin, ibuprofen, or naproxen and will suffer respiratory exacerbation if these drugs are taken in high doses. In this case, the addition of naproxen to ibuprofen-hydrocodone combo shifted the arachidonic acid metabolism causing excessive leukotriene (LT) production. Zileuton inhibits the formation of LT as will likely benefit this patient. Montelukast is LT receptor antagonist and will also be beneficial in this case. Montelukast is associated with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome).

Dupilumab is a monoclonal antibody against IL-4 receptor used in chronic sinusitis and polyps, asthma, and eczema. Mepolizumab is a monoclonal antibody against IL-5 used for the treatment of eosinophilic asthma. It has not been shown that dupilumab or mepolizumab are effective in treating NSAID exacerbated respiratory disease. The eosinophil count is normal in this case.

Azithromycin is a macrolide antibiotic used in the treatment of bacterial pneumonia and acute exacerbation of COPD.

Ipratropium is an anticholinergic agent used in COPD patients who do not respond to short acting beta-receptor agonists. While all anticholinergic agents (ipratropium, tiotropium, umeclidinium, aclidinium and glycopyrrholate) have equal efficacy, ipratropium is the only agent in class used in an acute exacerbation because it has the shortest half-life.

There is no point in adding a second long-acting beta agonist (LABA) to salmeterol. Formoterol, arformoterol, indacaterol and vilanterol are all LABAs that are essentially interchangeable, but do not add to each other.


August 4, 2020

Question Recap:  Which of the following is the best indicator to determine whether vitamin D supplementation is needed in a patient with hypocalcemia?

Responses Received from Members (551 Total):

 

 

 

Correct Response is:  A. 25-hydroxyvitamin D [25(OH)D] level

Question Explanation:  The correct answer is 25-hydroxyvitamin D [25(OH)D] level. Vitamin D is hydroxylated in the liver to 25(OH)D, which has a very long half-life (15 days), making it a good indicator of vitamin D store status in the body. 25(OH)D (also known as calcidiol) undergoes further hydroxylation in the kidney to become the active 1,25 (OH)D, also known as calcitriol, which has a relatively short half-life (15 hours). Calcitriol reflects PTH activity to stimulate renal conversion of calcidiol to calcitriol. Magnesium is involved in calcium hemostasis and metabolism. Certain drugs (example: proton pump inhibitors and thiazide diuretics) lower the level of magnesium. Hypomagnesemia decreases the sensitivity of tissues to PTH, resulting in hyperparathyroidism. However, hypomagnesemia does not in itself cause low vitamin D. PTH affects absorption, reabsorption, and resorption of calcium in the GI tract, kidneys, and bones, respectively. It does not have an effect on vitamin D level. For every 1 g/dL fall in serum albumin, there is a corresponding 0.8 mg/dL fall in serum total calcium. The vitamin D level is unaffected in hypoalbuminemia.

 

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