Cox’s Conference: Recurrent hypokalemia – Liddle Syndrome

In today’s Cox’s Conference, Dr. Jan Ramesh with expert discussant Dr. Biff Palmer presented a case of recurrent hypokalemia in the setting of lifelong hypertension that ultimately was diagnosed as Liddle Syndrome.

Continue reading Cox’s Conference: Recurrent hypokalemia – Liddle Syndrome

VA Morning Report: Ramsay Hunt Syndrome

Today at VA morning report, Dr. Grace Liu presented a case of Classic Ramsay Hunt Syndrome in a patient at the VA hospital!

The patient presented with right sided facial numbness and drooping, dry right eye, disequilibrium, decreased hearing in the right ear associated with painful vesicles in the right ear canal and tympanic membrane!

Read on for more on Ramsay Hunt Syndrome!

Continue reading VA Morning Report: Ramsay Hunt Syndrome

Image Challenge of the Week!

A 50-year old male presents with a chronic pruritic rash of his groin that failed to respond to topical antifungals and glucocorticoids. KOH stain was negative for fungal elements. Examination under Wood’s lamp revealed the following:

Sultan Qaboos Univ Med J. 2016 Aug;16(3):e381-2.

What is the diagnosis?

Scroll down for answer.

Continue reading Image Challenge of the Week!

Image Challenge of the Week!

A patient has undergone upper endoscopy for evaluation of dysphagia. You are present in the endoscopy suite and see the following on passage through the esophagus.

fixed tracheal rings.PNG
Curr Opin Gastroenterol. 2012 Jul; 28(4): 382–388.

What is this finding and the associated condition?

Scroll down for the answer.  Continue reading Image Challenge of the Week!

UT Southwestern Journal Watch 2017-18: 2nd Edition

The UT Southwestern Journal Watch group has released their next edition of the year. Shout out to the editors, authors, and their mentors for a fabulous job!

Highlights of this edition include: Cardiovascular testing in the emergency department, subclinical hypothyroidism in elderly, adiposity and the genetic risk of fatty liver disease, statins after adverse reactions, geriatric assessment and optimization in vascular surgery, health policy and influenza vaccination, emicizumab in hemophilia A, antibiotics in skin abscesses, methylprednisolone in IgA nephropathy, the ATHOS-3 trial, and tocilizumab in giant cell arteritis.

You can follow their twitter account (@UTSWIMJW) and blog ( to stay updated on news and their accompanying bimonthly publication. The editors (Tim Brown, Christina Yek, Stephanie Chiao, and Emily Bowen) can be reached on their respective Parkland emails or collectively at

Cox’s Conference: Antiphospholipid Antibody Syndrome

At today’s Cox’s Conference, Dr. Josephine Harrington with expert discussant Dr. Srikanth Nagalla of antiphospholipid antibody syndrome.


-Antiphospholipid antibody syndrome should be suspected in a patient with unprovoked venous and arterial thromboses, especially in a young patient without provocation. Testing can also be considered in women with histories of pregnancy loss, intrauterine growth restriction, preeclampsia, and abruption in settings in which antiphospholipid syndrome is suspected (testing should be limited to lupus anticoagulant, anticardiolipin Ab, and beta 2 glycoprotein Ab)

-Diagnosis is based on clinical criteria of thromboses or pregnancy morbidity in the presence of antiphospholipid antibodies. The antiphospholipid antibodies used in the Sapporo classification are anticardiolipin (IgG and IgM), anti-beta2-glycoprotein (IgG or IgM), and lupus anticoagulant. Repeat confirmatory laboratory testing of the above antiphospholipid antibodies should be confirmed >= 12 weeks apart

-Remember that you need clinical features and laboratory features to diagnosis antiphospholipid antibody syndrome. Thus, there is no value in testing asymptomatic patients

-Multiple positive antiphospholipid antibodies, particularly triple positive (anticardiolipin, anti beta2 glycoprotein, and lupus anticoagulant) are at higher risk of thrombosis

Q: What is the importance of diagnosing antiphospholipid antibody syndrome, particularly in men, who will not have the pregnancy related complications?

A: Antiphospholipid antibody syndrome, due to its high risk of recurrence, typically requires indefinite anticoagulation. This is in contrast to unprovoked or provoked venous thromboses, for which discontinuation can be entertained. However, patient risk factors for bleeding, patient preference, and antibody positivity (e.g. triple positive vs single positive) should be taken into consideration. Moreover, the diagnosis of antiphospholipid antibody syndrome has implications on choice of anticoagulation. The evidence for the use of direct acting anticoagulants is scant, partially due to the rarity of disease limiting feasibility of large scale trials. The RAPS trial demonstrated non-inferiority of rivaroxaban when compared to warfarin; however, surrogate markers of thrombogenicity were used and long-term studies examining the actual thrombosis event rate of rivaroxaban vs warfarin are lacking. Thus, there is a general bias towards vitamin K antagonists in the treatment of antiphospholipid antibody syndrome. Additionally, the knowledge that antiphospholipid syndrome is driving thrombosis may yield additional treatment considerations for recurrent thrombosis while therapeutic on vitamin K antagonists. Hydroxycholroquine has been suggested to decrease the risk of thrombotic events and may be considered as add-on therapy to anticoagulation in such patients.

Q: Can anticoagulation be discontinued based on falling titers of antiphospholipid antibody titers later in life?

A: This is a great question whose answer is waiting to be discovered.

JC 9.18.17 – HERA trial w/ Drs. Jae Sim, Nagalla, Sadeghi, and Dowell

We had an awesome oncology-themed Journal Club with Dr. Jae Sim presenting the landmark HERA trial (Trastuzumab after Adjuvant Chemotherapy in HER2-Positive Breast Cancer), which was published in NEJM in 2005. This study showed significant improvement in disease-free survival among women with HER2-positive breast cancer treated with 1 year of adjuvant trastuzumab after chemotherapy.

A special thank you to our faculty discussants: Dr. Nagalla at CUH, Dr. Sadeghi at Parkland, and Dr. Dowell at the VA for leading such wonderful discussions!

Below is a summary of the questions/discussions from all 3 sites: Continue reading JC 9.18.17 – HERA trial w/ Drs. Jae Sim, Nagalla, Sadeghi, and Dowell

UTSW Internal Medicine

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