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WuidQ: Washington University ID Questions Profile picture
@WuidQ
Mar 31, 2020 • 13 tweets • 6 min read • Read on X
#idgrandrounds
1/2
 68/M +progressive L facial/arm numbness & weakness, R hip pain x 6 wks. +malaise/wt loss but no fever. Exam: no rashes, +dysarthria. Labs: U/R.

Brain MRI: 2x2 cm R thalamic mass w/ vaso edema
CT: speculated RUL mass, sclerotic R iliac crest/SI joint

👇
2/2
 Lives in rural IL near a creek. Stays at home w/ a dog. Loves to garden. No travel, incarceration.

Neurosurgery performed burr hole/biopsy of mass (c/f glioblastoma). ID was consulted when biopsy came out.

What is your ddx/dx? @TxID_Edu @jdcooperid @GermHunterMD
1/11 Biopsy of brain mass: broad-based budding yeast, Cx: Blastomyces dermatitidis. Urine Histo Ag: low positive

CASE RESOLUTION: Disseminated blastomycosis

@LemuelNonMD @TxID_Edu @Cortes_Penfield @KartikAcharyaID @IDdoc_Vetri @jdcooperid got the correct Dx/Ddx! Thank you.
2/11 When we hear a patient w/ co-occurrence of lung-brain infection, Nocardia seems to be the #1 thought (at least on google search).

But the Ddx is actually very broad as some of you have pointed out. The table 👇 summarizes some of the Ddx. Image
3/11 Incidental finding of an infection on a biopsy specimen in a patient suspected of having malignancy is NOT unique to blastomycosis. True for many other fungal, mycobacterial, or even parasitic infections [#spacedlearning Check out case of Dirofilaria 👇]
4/11 But misdiagnosis of lung cancer is particularly common in pulmonary blastomycosis.

▪️Mass-like lesion, 2nd most common after alveolar infiltrates
▪️Lung mass resection in 55% of cases bit.ly/2R5yAu5

Blasto also mistaken for skin, brain, & laryngeal cancer.
5/11 Occurrence of lung-brain-BONE infection is also not unique to blastomycosis. Note however:

▪️Lung > skin > bone: top 3 most common sites of infection for both blastomycosis and coccidioidomycosis

Pathology & culture will ultimately provide dx.
6/11 The endemic mycoses are difficult to distinguish clinically from each other, especially in regions where there is geographic overlap. But some notable features:

▪️Blasto: pseudoepitheliomatous hyperplasia (verrucous skin lesions), GU involvement (4th common SSX, prostatits)
7/11 Also:

▪️Cocci: solitary peripheral thin-walled cavity, peripheral eosinophilia, skin predilection to the nasolabial fold

▪️Histo: oral ulcers very common in disseminated disease
8/11 In summary:

▪️Keep blasto (& a lot of other infections) as ddx for lesions that appear malignant clinically/imaging
▪️Lung, skin, bone, GU: most common SSX of blasto
9/11 #spacedlearning #retrieval Time to review other tweetorials of topics we’ve talked about in this thread.

Disseminated blasto (p/w skin-brain infections) 👇
10/11 Cerebral mucormycosis in PWID 👇
11/11 Lemierre syndrome w/ septic brain embolization 👇

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More from @WuidQ

WuidQ: Washington University ID Questions Profile picture
Jan 6, 2021
38/M w/ progressive loss of scalp, axilla, and chest hairs. Recently dx w/ HIV 6 mos ago when he developed dissem cryptococcosis. He has now been taking TDF/FTC, raltegravir, TMP/SMX, azithromycin, & fluconazole x 6 mos. Drug-induced alopecia is suspected. Most likely culprit?
1/8 Nice job! 52% got the right answer, fluconazole.

In animals/humans, fluconazole has been shown to induce telogen effluvium bit.ly/2MMnF9j, one of the most common causes of nonscarring hair loss (see Table 👇 bit.ly/38rTXyN).

@LParraRod @NNolanMD Image
2/8
 Normal hair cycle: anagen (growth) 👉catagen (transformation) 👉telogen (resting) 👉 shedding. Cycle is asynchronous (no mass hair shedding). At any given time, 90% of hair are in anagen, 1% in catagen, 10% in telogen.

@ID_fellows @PBMazi @LeMiguelChavez @gayathri25788
Read 9 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 24, 2020
32/M, h/o HSV encep 1 mo ago (s/p 21 d ACV), on ceftri/metronidazole for sacral OM, p/t ER +delusion, fever, seizure. CSF: WBC 25 (L>N), ⬆️TP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
b/l temporal lobe enhancement ⬆️ from prior. Whch of the ff is the best Tx for this condition?
1/11
The group is split b/n steroids & d/c metronidazole. The answer here is Tx w/ steroids. Indeed, this is a case of autoimmune post-HSV encephalitis (anti-NMDA receptor encephalitis post-HSV). Good job @LemuelNonMD
@LeMiguelChavez @adilrashid83 @Orchid10Tree @KhalafSuha
2/11
Metronidazole-induced encephalopathy is predominated by cerebellar Sx w/ a distinct involvement of the dentato-rubro-olivary pathway on imaging. We’ve talked about it here before. Refer👇for further discussion
Read 12 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 19, 2020
67/M w/ poor control DM, BPH, +10 d dysuria. T38.1, BP 120/80, +tender R CVA. WBC 14. U/A: 21 WBC, UCx: (-)bacteria, +Candida glabrata (fluc-R) x 2 samples. BCx(-), CT: +prostate hypertrophy. Has had no response to ceftriaxone. Has no Foley cath. Which of the ff is indicated?
1/15
The vote is split b/n micafungin and ampho deoxycholate! Thank you for all your responses!

Although micafungin may be a reasonable option, the correct answer here is ampho deoxycholate.

In this tweetorial, we will talk about Candida UTI and its treatment.
@ID_fellows
2/15
Candiduria can be challenging as it can potentially indicate: colonization, UTI, or candidemia/disseminated infxn.

Candiduria from a clean-voided urine sample is uncommon (<1%); more commonly seen in hospitalized patients w/ an indwelling bladder cath.
Read 16 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 16, 2020
ID Miscellany|physical Exam|Signs|Humanities #idmesh
1/20
𝙁𝙀𝙑𝙀𝙍 𝙋𝘼𝙏𝙏𝙀𝙍𝙉𝙎: 𝘼 𝙇𝙊𝙎𝙏 𝘼𝙍𝙏?

Great! Three quarters find inquiring about fever patterns still useful. We will review some of the most important fever patterns.

@ID_fellows

2/20
For centuries, physicians have relied upon meticulous observations to dx infections. For many years, observation of the fever pattern provided physicians w/ important diagnostic clues. However, the advent of abx & advanced dx & imaging has changed this landscape. #idmesh
3/20
Swift initiation of abx & antipyretics make it impossible to verify historical descriptions of certain fever patterns. Hence, inquiry into fever patterns loses its clinical significance bit.ly/33iXCLs.
Read 21 tweets
WuidQ: Washington University ID Questions Profile picture
Sep 11, 2020
29M w severe persistent asthma p/w recurrent exacerbations despite optimal LABA/intranasal steroids. Abs eos 1250, total Ig E 1500, CT +mucus plugging, central bronchiectasis upper-middle lobes. Originally from Mexico, now in Texas. Which of the ff tests is indicated?
1/10
Great job! The majority got the right answer, allergic bronchopulmonary aspergillosis (ABPA).

Recurrent asthma exacerbations despite optimal asthma therapy & eosinophilia a/w mucus plugging and multilobar central bronchiectasis should raise suspicion for ABPA.
2/10
Aspergillosis, classified as saprophytic (aspergilloma), allergic (ABPA, hypersensitivity pneumonitis, allergic sinusitis), or invasive (pulmonary, other organs).

ABPA: hypersensitivity to A. fumigatus; can also occur from other fungi (referred as ABPM, M for mycosis).
Read 11 tweets
WuidQ: Washington University ID Questions Profile picture
Jul 31, 2020
48M +cirrhosis, underwent routine large volume paracentesis. +Abd fullness, (-)fever, abd pain/tenderness, confusion. Ascitic fluid: light yellow, 100 PMNs, SAAG 1.5, Cx +pan-susc E. coli. WBC 8, Crea 0.8, bili 1.8. Which of the ff is best management for this patient?
1/5
 Only 21% got this right: no abx, repeat para in 48H.

The dx of spontaneous bacterial peritonitis (SBP) rests on finding >/= 250 PMNs/mm3 in the ascitic fluid. Most patients with SBP are symptomatic (only 13% with no symptoms bit.ly/3gp5nEU)
2/5
The patient in our case is asymptomatic (no fever, abdominal pain, mental status change 👉most common SBP symptoms) and the ascitic fluid is <250. This is a variant of SBP known as:

▪️Monomicrobial nonneutrocytic bacterascites (MNB)
Read 6 tweets

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