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Incidental (or Accidental) Findings in the Immunosuppressed Population

Incidental (or Accidental) Findings in the Immunosuppressed Population. Dr. Nate Miller Academic Assistant Professor University of South Dakota Sanford School of Medicine Avera McKennan Hospitalist. Disclaimer!. Sequence of events that occurred are altered for purpose of presentation

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Incidental (or Accidental) Findings in the Immunosuppressed Population

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  1. Incidental (or Accidental) Findings in the Immunosuppressed Population Dr. Nate Miller Academic Assistant Professor University of South Dakota Sanford School of Medicine Avera McKennan Hospitalist

  2. Disclaimer! • Sequence of events that occurred are altered for purpose of presentation • Data is not altered

  3. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary • CC: Weakness • HPI • +positional headache x 6 weeks • Occipital region • Lasts for seconds • No other exacerbating/alleviating factors • difficulty with walking due to decreased strength. • Negative fever, chills, lightheadedness, changes in vision, myalgias , arthralgias • Medications • Prednisone 20mg po daily • Bactrim DS po bid Mon, Wed, Fri • Levaquin 750 mg po daily q48 hrs x 10 days

  4. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary • PMH • Wegner’s Granulomatosis (Dx. November 2011) • CKD IV • Chronic mastoiditis (New diagnosis) • SH • Aberdeen area • 30 pack year • FH • Non-contributory • ROS • Negative except as noted in HPI.

  5. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary PE: General:Pleasant, fatigued 76 y/o Caucasian man resting comfortably in bed in no obvious acute distress VS:BP 128/86 P 97 R 20 T 98.5 02 100% on 2.5 lpm HEENT:Fundi exhibit well demarcated disks bilaterally. Skin:No new rashes or lesions Pulm:CTA bilat. Card:RRR. No m, r or g. Normal s1/s2. Musc:Negative UE/LE atrophy bilat. Neuro:Unable to walk secondary to weakness. 2+ patellar and bicipital reflexes bilat. Grip strength 3/5 bilaterally. Flexion/extension @ knee 3/5 bilat.

  6. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary LFTs: WNL Albumin: 4.0 10 160 7 31 139 99 39 168 3.8 29 2.4 BC: 1 of 2 + yeast

  7. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary CSF Fluid Wbc: 108 w/53% lymph Glucose: 22 Protein 143 Gram Stain: moderate WBC and no organisms India Ink Stain: Positive for encapsulated yeast Cryptococcal antigen (CSF): + Fungal culture (csf): 2/2 + for C. neoformans Blood Culture: 2/2 + for C. neoformans

  8. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary Epidemiology Clinical Manifestations Sub-acute meningitis Headache Lethargy Memory Loss Fever Cranial nerve palsies Meningeal symptoms • Port of entry • Lungs • Most common in immunosuppressed • HIV • Solid organ transplant • Hematologic malignancies • Chronic steroid use

  9. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary Diagnosis Diagnosis Cryptococcal Antigen (90% sensitive and specific) CSF Blood Culture (Gold Standard) 3-7 days India Ink Stain (50-80% sensitivity)

  10. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary Therapy Induction Amphotericin B & Flucytosine Consolidation Fluconazole Maintenance Fluconazole • Three phases if HIV + • Induction • Consolidation • Maintenance • Non-HIV • Induction

  11. The Real Story! • Patient admitted initially for dyspnea • Diagnosed with pulmonary embolus • “Routine” blood cultures ordered • Day 5 • 1 out of 2 +for yeast • Initially thought to be a “contaminant”

  12. Case PresentationDiagnosis?EpidemiologyClinical ManifestationsDiagnostic StudiesTherapySummary • Immunosuppressed Population • Increased Risk for atypical Infections • Cryptococcal Meningitis presentation is not one of “classic” meningitis • Presumptive diagnosis made with + cryptococcal antigen and confirmed with culture. • Cryptococcal meningitis left untreated is fatal

  13. References • Safdar N, Abad C, Narayan S, Kaul Dr, Saint S. Keeping an Open Mind. N Engl J Med. 2009;360:72-6. • Perfec JR. Cryptococcus Neoformans. In: Mandell G, Bennett JE, Dolin R, ed. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7th edition. Philadelphia, PA: Elselvier; 2010:3287-3303. • Pabla M, Gupta C, Singh J. A Revealing Stain. Am Fam Physician 2007 Feb 15;75(4):541-3.

  14. Case PresentationClinical ManifestationsDiagnosisTherapy • SH • Pierre area • 5 children • 40 pack year hx; Quit 17 years ago • Non-drinker • FH: Prostrate cancer

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