All posts by The Chiefs

Cox’s Conference: Mucormycosis

In this week’s Ambulatory Cox’s Conference, Dr. Jasmine Sukumar presented a case of a 50 year old man with history of alcohol cirrhosis, uncontrolled diabetes, and rectal cancer on chemotherapy who presented with right sided vision loss for 1 day. Our expert discussant, Dr. Pearlie Chong guided us through infectious complications to consider in an immunocompromised host.

The differential diagnosis for our patient with acute persistent vision loss included diabetic retinopathy with vitreous hemorrhage, retinal detachment, glaucoma, retinal artery or vein occlusion, optic neuritis, and giant cell arteritis. On exam the patient was found to have swelling and redness of the right eye with associated cranial nerve deficits. Based on the exam and the patient’s past medical history, we had to consider potentially less common etiologies of vision loss including intracranial malignancy (or metastasis), CMV retinitis, or invasive fungal infection. Imaging of the head and sinuses revealed thickening of the right ethmoid and maxillary sinus as well as a large soft-tissue mass in the retroorbital area. Surgical biopsies were performed that showed broad, irregularly branched hyphae with rare septations consistent with Rhizopus oryzae.

Mucormycosis Pearls:

·     Mucormycosis is a life-threatening fungal infection that typically affects immunocompromised patients as well as those with diabetes mellitus.

·     Infections in humans are most commonly caused by Rhizopus, Mucor, and Rhizomucor. These organisms are ubiquitous in nature and commonly found in soil and decaying vegetation.

·     In addition to immunocompromised patients, those with hemochromatosis (particularly those receiving deferoxamine therapy) and burn/trauma patients are also at risk of mucormysosis.

Clinical Presentation:

·     Most common clinical presentation in rhino-orbital-cerebral infection caused by inhalation of spores into the paranasal sinuses.

o     Common presenting complaints are fever, headache, nasal congestion, purulent nasal discharge, and sinus pain.

o     If the infection spreads beyond the sinuses, nearby structures can be involved resulting in perinasal swelling, palate eschars, and erythema or necrosis of the skin overlying the sinuses or orbit.

o     Signs of orbital involvement include periorbital edema, proptosis, and blindness as in our patient. Spread to the nearby cavernous sinus can result in cranial nerve palsies.1

·     Mucormycosis can also present with pulmonary, gastrointestinal, cutaneous, renal, or isolated CNS involvement. Disseminated disease occurs in severely immunocompromised patients.

·     Interestingly, many diabetic patients had ketoacidosis at the time of presentation.2


·     As Mucormycosis is a rapidly progressive, fatal disease, prompt diagnosis and empiric treatment is crucial.

·     Diagnosis relies on identification of the organism in tissue by histopathology, which requires a tissue biopsy. Cultures often yield no growth.

·     The 1,3-beta-D-glucan assay and the Aspergillus galactomannan assay will be negative in these patients.


·     Treatment requires both surgical deridement of involved tissues as well as antifungal therapy.

·     It is also important to eliminate any potential predisposing factors for this infection including hyperglycemia, deferoxamine administration, immunosuppressive medications, and neutropenia.

·     First line therapy is intravenous amphotericin B at 5-10mg/kg daily. After a patient has shown clinical improvement, the patient can be transitioned to posaconazole.3

·     Some data suggests improved patient outcomes with addition of caspofungin to amphotericin B compared to amphotericin B monotherapy. However larger studies are needed to establish whether combination therapy is truly beneficial.4

·     Despite appropriate antifungal therapy, aggressive surgical debridement is required for adequate disease control.


1.     Yohai RA, Bullock JD, Aziz AA, Markert RJ. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol 1994; 39:3.

2.     McNulty JS. Rhinocerebral mucormycosis: predisposing factors. Laryngoscope 1982; 92:1140.

3.     McCarthy M, Rosengart A, Schuetz AN, et al. Mold infections of the central nervous system. N Engl J Med 2014; 371:150.

4.     Reed C, Bryant R, Ibrahim AS, et al. Combination polyene-caspofungin treatment of rhino-orbital-cerebral mucormycosis. Clin Infect Dis 2008; 47:364.

Cox Conference: Ipilimumab-Induced Hypophysitis

In this week’s Ambulatory Cox’s Conference, Dr. Namrah Siddiq presented a case of a man with history of malignant melanoma on ipilimumab who presented with nausea, vomiting, and altered mentation. Further evaluation discovered that the patient had severe hyponatremia. Our expert discussant, Dr. Jessica Abramowitz guided us through immune checkpoint inhibitor related endocrinopathies.

Our differential diagnosis for an elderly patient with nausea, vomiting, and altered mental status initially included commonly encountered illnesses including viral gastroenteritis, urinary tract infection, dehydration, small bowel obstruction, malignancy (gastrointestinal tract tumor or metastatic disease), medication side effects, and metabolic disturbances. After we discovered the patient had a history of melanoma and was on ipilimumab, an immune checkpoint inhibitor that targets CTLA-4, our differential broadened to include ipilimumab-related enterocolitis, hepatitis, and hypophysitis. In the setting of severe hyponatremia, the patient was found to have an AM cortisol of 1 mcg/dL, undetectable TSH, and low free T4. Findings were consistent with hypophysitis, a known adverse effect of immune checkpoint inhibitors.

Immune Checkpoint Inhibitor Induced Hypophysitis Pearls:

  • Immune checkpoint inhibitors are a type of immunotherapy that use a patient’s immune system to fight their disease. They have provided significant benefit for a range of different cancer types and in patients who may not have had good treatment options in the past.
  • A number of immune-mediated adverse reactions have been described including enterocolitis, hepatitis, dermatitis, pneumonitis, nephritis, encephalitis/aseptic meningitis, myocarditis, and endocrinopathies (thyroid disease, diabetes, hypophysitis, and adrenal insufficiency). – NEJM paper.1
  • Hypophysitis is an inflammation of the pituitary gland with varying effects on pituitary hormone function. Most commonly presents with central adrenal insufficiency but may have central hypothyroidism, diabetes insipidus, or hypogonadism.
  • Hypophysitis has been described in 11-17% patients on ipilimumab. Ipilimumab in particular appears to most commonly be associated with hypophysitis.2

Clinical Presentation:

  • Patients will typically present with a constellation of symptoms including headache and vision changes along with symptoms of the various hormone deficiencies:
    • ACTH Deficiency – More mild symptoms ranging from fatigue, anorexia, weight loss, nausea/vomiting, postural hypotension, and tachycardia to severe symptoms including vascular collapse or death. Patients may have hyponatremia due to inappropriate secretion of antidiuretic hormone.
    • TSH Deficiency – Fatigue, cold intolerance, decreased appetite, constipation, dry skin, bradycardia, menstrual irregularies, and anemia.
    • FSH/LH Deficiency – Amenorrhea, infertility, hot flashes, and low libido.


  • Tests to order include electrolytes (BMP), morning cortisol, TSH and free T4, and ACTH.
  • Can consider ordering LH, FSH, and testosterone levels in males or premenopausal females with complaints of fatigue, loss of libido, and mood changes.
  • Consider MRI of brain with pituitary/sellar cuts in patients with multiple endocrine abnormalities.3
  • Patients with hypophysitis will have low ACTH and low cortisol, low or normal TSH with a low free T4, and low testosterone or estradiol with low LH and FSH.
  • Metabolic abnormalities can occur. In the case of central adrenal insufficiency and hypothyroidism, will have hyponatremia. With central diabetes insipidus, patients can have hypernatremia and volume depletion.


  • Temporarily withhold ipilimumab for symptomatic endocrinopathies.
  • Initiate appropriate hormone replacement therapy. In this case, the patient was started on stress dose steroids, hydrocortisone 150mg per day divided into 3-4 doses. He was also started on IV levothyroxine for thyroid hormone replacement.
  • It is important to use steroids with both glucocorticoid and mineralocorticoid effects such as hydrocortisone.
  • When a patient has hypophysitis with adrenal insufficiency and hypothyroidism, it is important to give the corticosteroids prior to thyroid hormone to prevent precipitating adrenal crisis.
  • After the endocrinopathies are stabilized on replacement hormones, patients can be restarted on ipilimumab with close monitoring by an endocrinologist.
  • Educate patients on increasing steroids during times of illness or surgery. They should also be told to get a medical alert bracelet for adrenal insufficiency. 3


  1. Postow MA, Sidlow R, Hellman MD. Immune-Related Adverse Events Associated with Immune Checkpoint Blockade. NEJM 2018.
  2. Faje A. Immunotherapy and hypophysitis: clinical presentation, treatment, and biologic insights. Pituitary 2016; 19:82.
  3. Brahmer JR, et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2018.

Dr. Allison Lange Publishes!

R3 Dr. Allison Lange published a case report today in BMJ Case Reports. She took care of a patient with a history of dermatomyositis who presented to the hospital with fevers and arm pain. The patient was found to have CMV viremia which then precipitated HLH/macrophage activation syndrome. This case report represents the first such report of CMV viremia causing MAS in a patient with dematomyositis.

Dr. Lange wrote this report with Dr. Kazi (our program director), Dr Chen (of hematopathology), and Dr. Barnes (infectious diseases). Great work!

The paper can be found here:

Cox’s Conference: Post-Pericardiotomy Syndrome

In this week’s Ambulatory Cox’s Conference, Dr. Neela Thangada presented a case of a female with history of hypertension, type 2 diabetes, and adrenal insufficiency secondary to pigmented nodular adrenocortical disease who presented with a chief complaint of shortness of breath, one week in duration. Our expert discussant, Dr. Ian Neeland guided us through the differential diagnosis for acute, progressive shortness of breath.

The young female patient was also experiencing orthopnea, paroxysmal nocturnal dyspnea, and exercise intolerance, all symptoms concerning for heart failure. Exam was pertinent for jugular venous distention, muffled heart sounds, and diffuse crackles. Our differential for acute onset of heart failure included myocarditis, myocardial infarction, valvular disease (acute aortic insufficiency), cardiac tamponade, constrictive pericarditis, infiltrative cardiomyopathies, familial cardiomyopathies, endocrinopathies (hyperthyroidism, hypothyroidism, adrenal insufficiency, and acromegaly), and nutritional deficiencies leading to heart failure. A bedside echocardiogram was performed that revealed a pericardial effusion. The patient had a notable history of recent sternotomy for anterior mediastinal mass resection, which made post-pericardiotomy syndrome the likely diagnosis.

Post-Pericardiotomy Syndrome Pearls:

  • Post-cardiac injury syndrome is pericarditis with or without a pericardial effusion as a result of injury to the pericardium.
  • Commonly occurs post-myocardial infarction, known as Dressler Syndrome.
  • However patients can also develop a similar syndrome after cardiac surgery, thoracic surgery that disturbs the pericardium, cardiovascular interventions (percutaneous coronary intervention, pacemaker lead insertion, and radiofrequency ablation), or trauma.1

Clinical Presentation:

  • Occurs after injury to or invasion of the pericardium or myocardium.
  • Typically there is a latent period, weeks to months, between the injury and the development of pericarditis or pericardial effusion.
  • Symptoms include pleuritic chest pain, fever, but heart failure symptoms can occur in the setting of pericardial effusion. Pericardial tamponade is rare (~ 2%).2


  • Suspected based on clinical picture (fever, chest pain, shortness of breath) in the setting of recent myocardial infarction or pericardial injury.
  • Laboratory abnormalities include leukocytosis and elevated erythrocyte sedimentation rate and C-reactive protein.2
  • EKG can have diffuse ST-segment elevation and PR depression.
  • Echocardiogram can reveal pericardial effusion.


  • First-line treatment consists of NSAIDs (if there are no contraindications) and colchicine.
  • In cases of refractory disease, systemic glucocorticoids (prednisone at 0.25 – 0.50 mg/kg/day) can be used.3
  • Colchicine may also be effective in prevention of post-pericardiotomy syndrome after cardiac surgery.4


  1. Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J 2006; 99:309.
  2. Imazio M, Brucato A, Rovere ME, et al. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol 2011; 108:1183.
  3. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
  4. Finkelstein Y, Shemesh J, Mahlab K, et al. Colchicine for the prevention of postpericardiotomy syndrome. Herz 2002; 27:791.

VA Morning Report- The Pulseless Disease

Yesterday, R3 Dr. Brandon Jakubowski presented a case he initially saw in PRIME clinic – a young lady who presented with a papular rash on her chin. The rash was initially treated conservatively, however progressed and involved painful pustular lesions on the patient’s arms. The patient was seen by dermatology and underwent a biopsy, however ended up going to the emergency room prior to the pathology resulting. In the ER, the patient was hypotensive and was noted to have absent upper extremity pulses. A CT scan was performed and aided in diagnosing Takayasu’s arteritis.


For research purposes, the American College of Rheumatology developed diagnostic criteria for Takayasu Arteritis in 1990. Patients must meet at least three of the following six criteria:

  • Age of onset ≤ 40 years old
  • Claudication of extremities
  • Decreased brachial artery pulse
  • Blood Pressure difference > 10mmHg between arms
  • Bruit over subclavian arteries or aorta
  • Arteriogram abnormality (narrowing or occlusion of the entire aorta, its primary branches or large arteries in the proximal upper or lower extremities, not due to arteriosclerosis, fibromuscular dysplasia or similar causes; changes usually focal or segmental)

The modified Ishikawa diagnostic criteria is slightly more complicated but has a higher sensitivity and specificity (92.5% and 95%, respectively) than the original ACR criteria and is notable for removing the age criteria.

In the management of Takayasu Arteritis, immunosuppressants are the cornerstone of therapy, however optimal management is undefined. This particular patient received high dose steroids, then transitioned to tocilizumab when side effects were no longer manageable. It is important to understand that laboratory findings do not reliably track disease activity and therapy is essentially guided by patient symptoms.


Further reading:

Arend WP, Michel BA, Bloch DA , et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33:112934.doi:10.1002/art.1780330811

Kim ESH, Beckman J. Takayasu arteritis: challenges in diagnosis and management. Heart. 2018 Apr;104(7):558-565. doi: 10.1136/heartjnl-2016-310848. Epub 2017 Nov 25.



Cox’s Conference – Sweet’s Syndrome

In last week’s Ambulatory Cox’s Conference, Dr. Stephen Philip presented a case of a female with history of rheumatoid arthritis who presented with a chief complaint of fever and rash. Initial laboratory studies unveiled an active urinary sediment concerning for glomerulonephritis. Our expert discussant, Dr. Biff Palmer guided us through the differential diagnosis for fever and rash with renal involvement.

In a patient who presents with fevers and rash, the differential diagnosis is broad and includes infectious, autoimmune, neoplastic, and drug-related etiologies. Our patient had evidence of renal involvement with an active urinary sediment concerning for glomerulonephritis. Our differential diagnosis in this patient included systemic lupus erythematosus, vasculitis (IgA vasculitis, ANCA-associated vasculitis, or cryoglobulinemia), common viral illnesses (EBV, CMV, and HIV), infective endocarditis, disseminated fungal infection, and cutaneous malignancy. The patient underwent a skin biopsy which confirmed the diagnosis of Sweet’s Syndrome.

Sweet’s Syndrome Pearls:

·     Also known as acute febrile neutrophilic dermatosis

·     Characterized by abrupt onset of painful, erythematous papules, plaques, or nodules which is frequently accompanied by fever and leukocytosis.

·     Neutrophilic infiltration to other organ systems can very rarely occur, including ocular, musculoskeletal, central nervous system, cardiovascular system, pulmonary system, gastrointestinal tract/liver, and kidneys. Renal involvement, as in our patient, is rare but commonly presents with proteinuria, less commonly with hematuria or renal insufficiency.1-2

·     Most commonly associated with infections (after URI or GI infection), inflammatory bowel disease, pregnancy, autoimmune diseases (RA, SLE, dermatomyositis, sarcoid), malignancies (more commonly hematologic malignancies), and drug related (most common is G-CSF).

Clinical Presentation:

·     Patients will have abrupt onset of painful inflammatory papules, plaques, or nodules. The distribution will be asymmetric with the upper extremities most commonly effected.

·     Often associated with fever, arthralgias, headache, myalgias, and malaise.

·     Extracutaneous involvement can occur, frequently ocular and musculoskeletal. However additional organ systems can also become involved.

·     Laboratory studies often show a peripheral leukocytosis with neutrophilia. An elevated erythrocyte sedimentation rate and C-reactive protein is common, along with anemia and platelet abnormalities.


·     Diagnostic criteria has been established – both major criteria is required along with two of four minor required.3

o     Major Criteria:

§     Abrupt onset of painful erythematous plaques or nodules

§     Histopathologic evidence of a dense neutrophilic infiltrate without evidence of leukocytoclastic vasculitis

o     Minor Criteria:

§     Fever, > 38 C

§     Association with underlying maligiancy, inflammatory disease, or pregnancy OR preceded by URI, GI infection, or vaccination

§     Excellent response to treatment with systemic glucocorticoids or potassium iodine

§     Abnormal laboratory values at presentation (need 3 of the 4: ESR > 20 mm/hr, positive C-reactive protein, > 8,000 leukocytes, > 70% neutrophils).


·     Corticosteroid therapy is first-line. Typically start with prednisone at 0.5 to 1mg/kg per day.

·     After initiation of steroid therapy, symptoms are expected to improve within 48 hours.

·     Once disease control is obtained, can begin to taper steroids with a plan to discontinue steroids within 4-6 weeks.

·     Other therapies such as colchicine, dapsone, and potassium iodide have been used as steroid-sparing agents.4


1.     Cohen PR, Kurzrock R. Sweet’s syndrome revisited: a review of disease concepts. Int J Dermatol 2003; 42:761-778.

2.     Vignon-Pennanmen MD. The extracutaneous involvement in the neutrophilic dermatoses. Clin Dermatol 2000;18:339–47.

3.     von den Driesch P. Sweet’s syndrome (acute febrile neutrophilic dermatosis). J Am Acad Dermatol 1994; 31:535.

4.     Cohen PR, Kurzrock R. Sweet’s syndrome: a review of current treatment options. Am J Clin Dermatol 2002; 3:117.

NEJM Res 360 Journal Club: Hosted by UTSW Internal Medicine Residency

UTSW has been chosen to work with NEJM hosting a journal club. We will be reviewing the paper “Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection” (ProACT). The Journal has recruited three of the study authors to help us provide some insight into the design and execution of the trial.

Please visit here for the discussion:

Anybody can access the discussion and contribute!


The paper can be accessed here:

VA QI Morning Report – PICC?

This morning at the VA we did a mini M&M based on this case regarding the appropriateness of PICC lines in a patient with CKD/ESRD with diabetes and osteomyelitis.

PICCs should generally be avoided in patients with an eGFR <45 ml/min/1.73m2 or placed only after consultation with a nephrologist. The reason for this is PICC placement can harm future candidacy for AV fistula placement, the safest and most effective method of hemodialysis.

There are alternatives for patients needing long-term IV access that may preserve the central and peripheral vasculature in the event HD is needed. The MAGIC criteria have helped to delineate the most appropriate intravenous catheter for your patient. The original paper, published in 2015, can be found here. The authors have also developed an app, which can be found here.


Parkland Morning Report 7/18 – Lupus Cerebritis

At today’s morning report at Parkland R2 Corbin Eule presented a case of a 68 year-old female with 2 weeks of confusion and lower extremity motor and sensory neuropathy, on a background of chronic fatigue, malaise and unintentional weight loss.

Our case discussion was led by pulmonary/ critical care faculty Dr Carlos Girod. The initial differential was broad and included malignancy with paraneoplastic syndrome, connective tissue disorders, and infiltrative disorders such as amyloidosis and sarcoidosis. The patient’s admission labs were notable for pancytopenia and normal renal function and urine sediment. An autoimmune panel was revealing with ANA >1:2560, positive anti-dsDNA antibodies, and low complement levels. Subsequent studies included a bone marrow biopsy showing LE cells and peripheral nerve biopsy consistent with vasculitis.

The patient was diagnosed with systemic lupus erythematosus (SLE) and received a course of “pulse” dose methylprednisolone followed by initiation of mycophenolate and an oral prednisone taper, with which she clinically improved.

SLE Pearls:

–     SLE may present with a wide variety of neuropsychiatric manifestations, including cognitive dysfunction, encephalopathy, polyneuropathy, psychosis, mood disorders, and coma1.

–     Neuropathy associated with SLE is thought to be due to vasculopathy of the small arteries supplying nerves; given the systemic nature of the disease, multiple nerves can be affected at once2.

–     LE cells were first described in 1948 by hematologists Dr Malcolm Hargraves and Dr Robert Morton, who found cells in the bone marrow of patients with SLE that appeared to have had their nuclei phagocytosed by mature polymorphonuclear cells3.

Clinical Presentation:

–     SLE is diagnosed by likelihood (definite, probable or possible SLE) using clinical and immunologic criteria such as that described by the American College of Rheumatology (ACR)4 or the Systemic Lupus International Collaborating Clinics (SICC)5.

–     The presence of neurologic manifestations in the absence of other known causes is one of the clinical criteria described by both societies, as is the presence of blood cell dyscrasias (hemolytic anemia, thrombocytopenia, leuko- or lympho-penia), and serum autoantibodies (ANA, anti-dsDNA, anti-Sm or antiphospholipid antibodies) that were seen in this case.


–     Treatment of SLE depends on the severity of the flare, with systemic corticosteroids and immunosuppressants forming the mainstay of treatment.

–     Determining dosing intensity and duration of corticosteroid therapy for treatment of SLE is challenging. Whereas historically “pulse” steroids (methylprednisolone 0.5 to 1g/day for 3 days) were commonly regarded as the gold standard for severe SLE flares, more recent evidence suggests that lower doses may be equally efficacious, with reduction in infectious side effects6.


1. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis and rheumatism. 1999;42(4):599-608.

2. Florica B, Aghdassi E, Su J, Gladman DD, Urowitz MB, Fortin PR. Peripheral neuropathy in patients with systemic lupus erythematosus. Seminars in arthritis and rheumatism. 2011;41(2):203-211.

3. Hepburn AL. The LE cell. Rheumatology (Oxford). 2001;40(7):826-827.

4. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis and rheumatism. 1997;40(9):1725.

5. Petri M, Orbai AM, Alarcon GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis and rheumatism. 2012;64(8):2677-2686.

6. Badsha H, Edwards CJ. Intravenous pulses of methylprednisolone for systemic lupus erythematosus. Seminars in arthritis and rheumatism. 2003;32(6):370-377.

Joey Harrington Publishes!


R3 Dr. Josephine Harrington published her new review “Should Metformin Remain First-Line Therapy for Patients with Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease? An Alternative Approach” today in Current Diabetes Reports.


Dr. Harrington reviews the evidence for cardiovascular effects of antihyperglycemic agents, proposing the major aim of therapy of type 2 diabetes should be to reduce CV events and deaths. In the face of newly developed diabetes therapies with proven CV safety, is metformin the best option to improve CV outcomes?


Dr. Harrington publishes this review with former UTSW IM resident and current UTSW cardiology fellow Natalia de Albuquerque Rocha, UTSW cardiology fellow Kershaw Patel , Dr. Subodh Verma, and UTSW Cardiologist Dr. Darren McGuire. The review can be found here.