Neurosyphilis… A Parkland Epidemic?

We recently had 2 fascinating cases of Neurosyphilis presented at Parkland morning report. The first case depicted a patient with cyclical nausea/vomiting related to tabes dorsalis and autonomic dysfunction. The second patient manifested visual disturbance as her primary complaint. Although considered rare in the modern age, Neurosyphilis is not uncommon at Parkland. In part, this may be due to a steady increase in primary and secondary syphilis over the last decade, especially in men who have sex with men.

Syphilis Stats

Clinical pearls for Neurosyphilis are listed below:

  • Neurosyphilis can occur at any time after initial infection.
  • Neurosyphilis can be classified into early forms and late forms. Early Neurosyphilis includes meningitis, meningovasculitis and ocular disease (almost any part of the eye is susceptible). Late Neurosyphilis involves general paresis, autonomic dysfunction and tabes dorsalis (locomotor ataxia, episodic abdominal pain/nausea/vomiting, Argyll-Robertson Pupil).
  • While a reactive CSF-VDRL establishes the diagnosis of neurosyphilis, a nonreactive test does not exclude the diagnosis. A CSF lymphocyte count >5 cells/microL or a protein concentration >45 mg/dL is consistent with the diagnosis of neurosyphilis, as well.
  • First line treatment includes IV penicillin G for 10 to 14 days

2016 Presidential Election: Healthcare on the Campaign Trail

Americans are held in suspense as each week approaching the 2016 election, a new potential political candidate is introduced to the growing pot of presidential hopefuls. Although the candidates remain unclear, one thing is for sure – healthcare reform will be a major debating point. With Medicaid expansions and the Affordable Care Act defining the past two terms, voters are still anticipating a bandaid for the seemingly struggling healthcare system. Physicians and patients are also eager to identify a leader who will be able to implement much needed changes. As more and more individuals throw their hats into the ring, it becomes every more important to understand their views on this issue. There are many more debates to come and this issue will certainly arise. While there is no perfect, unbiased resource for political issues, a good summary of the stance the candidates take on healthcare can be found here:

2016 Presidential Candidates on Healthcare

Guillain-Barré Pearls

Dr. Brian Davis presented an outstanding case of Guillain-Barré (GB) at Parkland morning report yesterday. Here are some useful clinical pearls:

  • GB is the most frequently acquired demyelinating peripheral polyneuropathy.
  • Pathophysiology is autoimmune and typically in response to a preceding viral or gastrointestinal infection.
  • Characterized by rapidly progressive weakness that is ascending and symmetric. Sensory involvement, such as paresthesias, are common.
  • Diagnosis is largely clinical but supported by EMG as well as characteristic CSF findings: cytoalbumin dissociation – elevated protein without white blood cells.
  • Potential therapies include IV Ig, plasma exchange and supportive measures (mechanical ventilation if needed). There is no definitive role for corticosteroids.
  • Prognosis is variable. 50% of patients recover completely and 50% have at least some degree of neurologic sequelae.

Annals of Internal Medicine Profiles the First Domestic Cases of Ebola

The Annals of Internal Medicine recently published a report profiling the first 2 domestic cases of Ebola in the United States. Before 2014, only 4 patients with Ebola had been treated in the US, all of them diagnosed in western Africa and evacuated for care. The article details the clinical course of the 45 year-old Liberian male and 26 year-old critical care nurse presenting to Dallas Presbyterian in September 2014. It does an excellent job scientifically depicting illness trajectory and management. An accurate understanding of the Ebola cases in Dallas is essential to improving our country’s response to future outbreaks.

Chronic Diarrhea – Diagnostic Dilemma

Chronic diarrhea generally refers to a duration of illness lasting at least 4 weeks and is fairly common with rates projected as high as 5% annually for the general population. Gathering a good history is key in guiding workup. While most infectious etiologies are excluded once the duration of illness meets the 4-week threshold, some pathogens, particularly C. difficile, Giardia, Yersinia, and Aeromonas may have a more indolent course. An excellent approach is found below in this algorithm:

Chronic Diarrhea Algorithm

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Electrolyte & Acid–Base Disturbances in Patients with Diabetes Mellitus

Our own master of electrolytes and kidney specialist, Dr. Biff Palmer, recently published an excellent review article in New England Journal of Medicine titled “Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus.” These frequently encountered clinical scenarios pose problems both in the inpatient and outpatient settings and it is important for physicians of all specialties to become familiar with common presentations and approach to workup and management.

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Drug-Induced Pancreatitis

Today at VA morning report, we had a great case of 6-mercaptopurine-induced pancreatitis presented by Dr. Nawaf Alrehani. While most cases of acute pancreatitis are mild, about 20% of patients develop severe disease and approximately 5% of patients die. It is important to identify predisposing factors early in the disease course to aid with management. In the US, about 80% of cases of acute pancreatitis in the United States are caused by alcohol use or gallstones and the incidence rate in the Western world is increasing.

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