It’s Monday, which means it is time for the image challenge of the week!
This week’s Cox’s Conference Case was presented by Dr. Varun Sondhi and led by discussant, Dr. James Luby. Continue reading Cox’s Conference: Ocular syphilis as a manifestation of early neurosyphilis
Nitin Kondamudi just published a review article titled ‘‘Exercise Training for Prevention and Treatment of Heart Failure” in Progress in Cardiovascular Diseases. Nitin discusses the role of physical activity and weight loss in preventing and treating heart failure.
Special thanks to mentors Dr. Jarett Berry and Dr. Ambarish Pandey in the Division of Cardiology.
This week at Parkland, Dr. Thomas Rose presented an interesting case of pulmonary mucormycosis in a 19-year old presenting in DKA. Fortunately, through quick identification and appropriate management, the patient is back at home and continuing to improve 6 months after her initial presentation! Continue reading Parkland Morning Report: Pulmonary Mucormycosis
Today Dr. Chris Wrobel presented an unfortunate case of an overwhelming sepsis and death from streptococcal meningitis that developed from mastoiditis.
Bryan Wilner published a study last week ”Dynamic Relation of Changes in Weight and Indices of Fat Distribution With Cardiac Structure and Function: The Dallas Heart Study” in the Journal of the American Heart Association (JAHA)
Dr. Emily Bowen presented a great case of salmonella infantis osteomyelitis in patient with sickle cell disease during morning report today.
Salmonella as a cause of osteomyelitis is RARE! These cases predominantly occur in patients with sickle cell or other hemoglobinopathies.
Patients with sickle cell disease have functional hypo-/asplenia from chronic microinfarctions leading to splenic atrophy. They are susceptible to infections with encapsulated organisms (e.g., pneumococcus, meningococcus, and SALMONELLA).
Why are asplenic patients at risk of infections with encapsulated organisms?
- Polysaccharide encapsulated organisms evade the innate immune system (C’ and other opsonins bind less effectively to the capsule –> less effective phagocytosis)
- Effective clearance of these organisms depends on production of pathogen-specific IgM antibodies, which are produced by the spleen
Why salmonella (vs. other encapsulated organisms) and why osteomyelitis?
- Possible hypothesis (courtesy of Drs. Brad Cutrell and Frankie Lee):
- Patients with SSD can have micro-infarctions of the bowel, followed by gut translocation of enteric organisms and bacteremia, followed by seeding of previously damaged/infarcted bone. That combined with diminished immunity and ability to clear infection = perfect storm
Treatment of salmonella osteomyelitis:
- Fluoroquinolones (e.g., ciprofloxacin)
- 3rd generation cephalosporins (e.g., ceftriaxone)
Today in VA morning report we had a lively discussion about esophageal problems with the lead discussant being our local esophagus expert Dr. Dunbar! Some quick PEARLS below!
- Typically presents with dysphagia to both solids and liquids
- Represents failure of relaxation of the LES (in most cases)
- Remember to perform an EGD on anyone with suspected achalasia in order to rule our “pseudoachalasia” which may be secondary to malignancy.
- Once EGD is performed, you can confirm achalasia with esophageal manometry.
- Treatment typically depends on whether the patient is low or high risk for surgery
- For low risk – Heller myotomy and pneumatic dilatation are the treatments of choice. Some studies show they are eually as effective
- For high risk – medical management with botulism injection into the LES can be very helpful
Diffuse Esophageal Spasm –
- Usually presents with chest pain
- Has a Corkscrew appearance on barium swallow caused by abnormal muscle contractions
- Treatment is medical and the drug of choice is a calcium channel blocker like diltiazem.
- Less effective treatments include nitrates and botulinum toxin
Eosinophilic Esophagitis – EoE
- Typically presents with dysphagia, food impaction, chest pain, and GERD
- EGD shows concentric rings and trachealization of the esophagus
- Biopsy will show many eosinophils (but this can also occur in GERD)
- Always treat with omeprazole first, because 30-40% of cases will respond to this!
- If not steroid responsive, fluticasone or budesonide inhalers can be used. These are sprayed into the mouth without inhalation, and then swallowed
- Pneumatic dilatation can be used for strictures as last resort, but there is increased risk of perforation!!
Thank you Dr. Dunbar for your excellent input on the disorders!
Imm, Nick. Achalasia. Digital image. N.p., 11 Aug. 2011. Web. 24 July 2017. <patient.info/doctor/achalasia-pro>.
Nevit, Dilman. Corkscrew Esophagus. Digital image. Wikipedia. N.p., 13 Dec. 1993. Web. 24 July 2017. <en.wikipedia.org/wiki/Diffuse_esophageal_spasm>.