Approximately 66% of post-mortem evaluations of the adrenal gland in HIV patients show abnormalities. Common infectious etiologies include CMV, Mycobacterium tuberculosis, Histoplasmosis, PCP, Toxoplasmosis, and Kaposi sarcoma.
A 28-year-old woman presented with paraplegia and abdominal pain. She had a history of type 2 diabetes for 6 years and was diagnosed with systemic lupus erythematosus based on positive ANA and anti-dsDNA tests. MRI showed disc bulges in her spine and she was found to have acute transverse myelitis. She developed recurrent urinary tract infections with Klebsiella that were difficult to treat. An abdominal mass was discovered on CT and biopsy was inconclusive. She required long-term antibiotic treatment and management of her neurogenic bladder and lupus.
This 47-year-old male with a history of liver cirrhosis and HBV was admitted to the ER for hemoptysis for 2 days. He has a left neck mass and complaints of dysphagia and bleeding after eating. A CT scan showed a bulky tumor involving the left lateral oropharyngeal, hypopharyngeal and laryngeal walls, with enlarged lymph nodes. A laryngoscopy found a left hypopharyngeal cancer with ulceration and blood clot but no active bleeding. The tentative diagnosis is left hypopharyngeal cancer with ulceration and active bleeding status post endotracheal intubation to protect the airway, along with anemia from tumor bleeding,
A 19-year-old male gym player presented with decreased urine output, fatigue, loss of appetite, joint pain, nausea, and vomiting for one week. Lab results showed impaired renal function. He has a history of artheralgia treated with long-acting penicillin. Investigations showed positive ANA and anti-ds DNA. A renal biopsy was done which revealed lupus nephritis class 4, indicating an active inflammation. The treatment plan includes high dose steroids, immunosuppressants, and supplements.
This case discusses an 18-year-old female patient presenting with easy fatigability and other symptoms over several months. After examination and investigations, she was diagnosed with systemic lupus erythematosus affecting multiple organs including the lungs, skin, kidneys, and central nervous system. She was started on treatment including steroids, antibiotics, and other medications. The case highlights the approach to diagnosing and managing SLE, a chronic autoimmune disease with diverse clinical manifestations and organ involvement.
A 7 year old girl presented with worsening fatigue and vomiting, and was previously treated with ibuprofen and diclofenac for tonsillitis, which likely caused acute interstitial nephritis and acute kidney injury. Further workup revealed polycystic kidney disease as an underlying cause of chronic kidney disease. Her kidney function improved after stopping the NSAIDs and hydration, but she ultimately required long-term dialysis due to her polycystic kidney disease.
This patient presents with a 3 month history of right leg pain on walking that resolves with rest. Examination finds the right leg cooler with sparse hair and thin skin. All pulses are absent below the femoral pulse. Doppler ultrasound finds softer signals in the right leg arteries and an ankle brachial pressure index of 0.6 on the right and 0.8 on the left. The patient has risk factors of smoking and diabetes. The clinical diagnosis is peripheral arterial disease and the patient is advised on lifestyle changes and medication while further investigation and monitoring is recommended.
This M&M presentation discusses the case of a 17-year-old female, JS, who underwent surgery to close an atrial septal defect. Intraoperatively, the surgeons discovered there was no defect present. This was an unexpected complication. The entire cardiac team was involved. Steps may have been missed in preoperative testing to detect there was no actual defect. A percutaneous procedure may have prevented this complication and resulted in a much shorter hospital stay for the patient.
A 28-year-old woman presented with paraplegia and abdominal pain. She had a history of type 2 diabetes for 6 years and was diagnosed with systemic lupus erythematosus based on positive ANA and anti-dsDNA tests. MRI showed disc bulges in her spine and she was found to have acute transverse myelitis. She developed recurrent urinary tract infections with Klebsiella that were difficult to treat. An abdominal mass was discovered on CT and biopsy was inconclusive. She required long-term antibiotic treatment and management of her neurogenic bladder and lupus.
This 47-year-old male with a history of liver cirrhosis and HBV was admitted to the ER for hemoptysis for 2 days. He has a left neck mass and complaints of dysphagia and bleeding after eating. A CT scan showed a bulky tumor involving the left lateral oropharyngeal, hypopharyngeal and laryngeal walls, with enlarged lymph nodes. A laryngoscopy found a left hypopharyngeal cancer with ulceration and blood clot but no active bleeding. The tentative diagnosis is left hypopharyngeal cancer with ulceration and active bleeding status post endotracheal intubation to protect the airway, along with anemia from tumor bleeding,
A 19-year-old male gym player presented with decreased urine output, fatigue, loss of appetite, joint pain, nausea, and vomiting for one week. Lab results showed impaired renal function. He has a history of artheralgia treated with long-acting penicillin. Investigations showed positive ANA and anti-ds DNA. A renal biopsy was done which revealed lupus nephritis class 4, indicating an active inflammation. The treatment plan includes high dose steroids, immunosuppressants, and supplements.
This case discusses an 18-year-old female patient presenting with easy fatigability and other symptoms over several months. After examination and investigations, she was diagnosed with systemic lupus erythematosus affecting multiple organs including the lungs, skin, kidneys, and central nervous system. She was started on treatment including steroids, antibiotics, and other medications. The case highlights the approach to diagnosing and managing SLE, a chronic autoimmune disease with diverse clinical manifestations and organ involvement.
A 7 year old girl presented with worsening fatigue and vomiting, and was previously treated with ibuprofen and diclofenac for tonsillitis, which likely caused acute interstitial nephritis and acute kidney injury. Further workup revealed polycystic kidney disease as an underlying cause of chronic kidney disease. Her kidney function improved after stopping the NSAIDs and hydration, but she ultimately required long-term dialysis due to her polycystic kidney disease.
This patient presents with a 3 month history of right leg pain on walking that resolves with rest. Examination finds the right leg cooler with sparse hair and thin skin. All pulses are absent below the femoral pulse. Doppler ultrasound finds softer signals in the right leg arteries and an ankle brachial pressure index of 0.6 on the right and 0.8 on the left. The patient has risk factors of smoking and diabetes. The clinical diagnosis is peripheral arterial disease and the patient is advised on lifestyle changes and medication while further investigation and monitoring is recommended.
This M&M presentation discusses the case of a 17-year-old female, JS, who underwent surgery to close an atrial septal defect. Intraoperatively, the surgeons discovered there was no defect present. This was an unexpected complication. The entire cardiac team was involved. Steps may have been missed in preoperative testing to detect there was no actual defect. A percutaneous procedure may have prevented this complication and resulted in a much shorter hospital stay for the patient.
The document describes a pediatric case study of a 4-month-old male, Baby CG, born with Tetralogy of Fallot (TOF). Baby CG underwent various procedures including balloon valvuloplasty, angioplasty, and full TOF repair surgery. Baby CG's labs showed abnormalities including low oxygen levels and high glucose levels after surgery, which improved over time. The document also details Baby CG's medications, nutrition, and growth charts pre- and post-operatively.
This case presentation summarizes the case of a 16-year-old female patient diagnosed with systemic lupus erythromytous. She presented with rashes on her face, swelling in her lower limbs, fever, hair loss, and shortness of breath. Her medical history, examinations, lab tests, treatment and management are documented in detail over her hospital stay. She was diagnosed with SLE based on her symptoms and tests showing positive rheumatoid factor and meeting four diagnostic criteria. She was treated with medications and discharged with instructions to follow up in the outpatient clinic.
CASE PRESENTATION ON RHEUMATOID ARTHRITISBinuja S.S
A 57-year-old female was admitted with non-healing ulceration of the left ankle, edema of both lower limbs, and joint pain with intermittent fever. Her history and examinations were consistent with rheumatoid arthritis. She was treated with aspirin, prednisolone, methotrexate, folic acid, and other medications. Her joint pain and edema improved over her 6-day hospital stay, and she was discharged on medications with follow-up planned.
Mr. X, a 25-year-old male, presented with a high fever for one week and one episode of vomiting. His medical history included diabetes and hypertension. On examination, his temperature was 104 F, pulse was 102 beats/min, and blood pressure was 110/80 mm Hg. Laboratory tests confirmed paratyphoid A fever. He was diagnosed with paratyphoid A fever and treated intravenously with cefoperazone, sulbactam, pantoprazole, ondansetron, and ofloxacin. Upon discharge, he was advised to take paracetamol and pantoprazole tablets.
This document describes the case of a 51-year-old male labourer admitted with fever, facial puffiness, haematuria, epistaxis and leg swelling for 3-7 days. Investigations revealed cANCA positivity and renal involvement. A renal biopsy showed focal segmental glomerulonephritis with necrosis, consistent with ANCA vasculitis. A diagnosis of Wegener's granulomatosis was made based on renal and upper respiratory tract involvement. The patient was started on steroids and cyclophosphamide for treatment.
Dr. Saumya Agarwal presented a case of a 75-year-old female who was brought to the hospital semiconscious after a motor vehicle accident. She had a past medical history of diabetes, hypertension, and heart disease. Despite treatment for her injuries including a fracture of the right elbow and left shoulder, her condition deteriorated and she went into cardiac arrest. Resuscitation efforts were unsuccessful and she was declared dead due to cardiogenic shock resulting from her injuries sustained in the accident.
A 67 year old male patient was admitted to the male medicine ward with complaints of abdominal distension, bilateral lower limb oedema, pitting pedal oedema, distended and swelled scrotum and breathlessness since 15 days.
This document describes the case of a 55-year-old man who experienced episodes of sweating, shortness of breath, and diarrhea for 10 months. Imaging showed a mass in his jejunum, which was resected and found to be a carcinoid tumor. Carcinoid tumors are often associated with heart lesions due to secretion of vasoactive substances. The expected heart lesion in this case would be carcinoid heart disease, characterized by plaque-like lesions in the heart valves.
A 74-year-old African American female was admitted to the emergency department with signs of hypoglycemia, excessive anticoagulation, anemia, and infections. Laboratory tests found abnormal liver and kidney function along with hypothyroidism and rheumatoid arthritis. The patient received treatments including dextrose for hypoglycemia, antibiotics for infections, vitamin K to reverse anticoagulation, blood transfusions for anemia, and prognosis was poor due to multiple declining organ functions and infections.
CASE STUDY ON UTI AND OBSTRUCTIVE JAUNDICERajesh Dutta
A 63-year old female presented with abdominal pain, yellow urine, and burning urination. Lab work showed elevated liver enzymes and bilirubin consistent with obstructive jaundice. Imaging revealed gallstones obstructing the common bile duct, causing jaundice. She was diagnosed with urinary tract infection, obstructive jaundice, and gallstones. Treatment included antibiotics, antacids, and antispasmodics.
The document discusses several cases of glomerular disease:
1) A 27-year-old male with nephrotic syndrome and a kidney biopsy showing IgG and C3 deposits along the glomerular basement membrane consistent with membranous nephropathy.
2) A 78-year-old female admitted with nephrotic syndrome after a history of NSAID use, with a biopsy showing focal segmental glomerulosclerosis.
3) A 26-year-old male with nephrotic syndrome and renal impairment, whose biopsy demonstrated membranoproliferative glomerulonephritis with C3 deposition and subendothelial electron dense deposits. Follow up showed elevated
This document summarizes a patient mortality meeting discussing a 45-year-old female patient who was admitted unconscious following a road traffic accident. She sustained injuries including a laceration on her right thigh and eye, as well as an intertrochanteric fracture of the right femur. The summary outlines her hospital course, management including surgery, complications including infections, and eventual discharge on day 26 after addressing cerebral salt wasting.
Mr. Lee, a 59-year-old Chinese man, was admitted to the hospital for acute upper gastrointestinal bleeding due to rupture esophageal varices from cirrhosis of the liver and portal hypertension. He underwent band ligation of the esophageal varices during his admission and showed improvement. At discharge, he was advised to follow up in 2 weeks and annually for endoscopy surveillance due to his cirrhosis, continue medications and lifestyle modifications, and seek immediate medical care if symptoms return.
A 54-year-old male farmer presented with fever, body aches, and jaundice for several days. He worked in fields and around animals. On examination, he was febrile and tachycardic with irregular pulse. Tests found elevated liver enzymes and leptospira IgM antibodies. He was diagnosed with severe leptospirosis (Weil's disease) due to his occupation and exposure. He received antibiotics and supportive care and recovered within two weeks. Leptospirosis can mimic other diseases but a high index of suspicion is important for farmers and those exposed to animals or fields.
1. The document describes the rules and questions for the AIIMS MEDICINE QUIZ finals with 6 clinical rounds.
2. The rounds involve teams answering direct clinical case questions and having the option to "pounce" on other teams' questions for additional points.
3. Sample questions cover topics like pulmonary actinomycosis, milk-alkali syndrome, necrotizing migratory erythema, beri-beri, hepatic encephalopathy, NMO, and various cardiac conditions.
13. a case study on convulsions in a kco epilepsy with lactational amenorrhoeaDr. Ajita Sadhukhan
A 25 year old female patient was admitted to the female medicine ward with complaints of 2 and a half month amenorrhoea, epileptic fit convulsions at home, vertigo, generalised weakness and 1 episode of epileptic fit today evening.
This document summarizes the medical history and treatment of a 50-year-old male patient presenting with fluid overload, decreased urine output, and severe breathlessness. The patient had a history of diabetes, hypertension, chronic kidney disease, and other comorbidities. During his hospital stay, he received treatment including hemodialysis, antibiotics, and other medications. His condition initially improved but he then developed sepsis and died on January 18th while being transferred for another hemodialysis session.
The document discusses two conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). PNH is a complement-mediated hemolytic anemia treated with the drug eculizumab, a C5a inhibitor. aHUS is a complement-mediated thrombotic microangiopathy that can cause stroke, heart attack, and kidney failure, and is also treated with eculizumab. The document asks the reader to identify PNH, aHUS, and the mode of action of eculizumab.
Case presentation on gastroenteritis and acute renal failureDr P Deepak
A 42-year old female patient presented with gastroenteritis and acute renal failure. She reported loose stools and vomiting for several days. Laboratory tests found elevated urea and creatinine levels indicating acute renal failure. She was diagnosed with acute gastroenteritis caused by Entamoeba histolytica and treated with intravenous antibiotics, antiemetics, and proton pump inhibitors. Her condition improved over the next few days with reduced vomiting and stool frequency.
A 48-year-old female presented with left foot gangrene, drug-induced Cushing's syndrome, rheumatoid arthritis, and type 2 diabetes. She reported pain and swelling in her lower limbs and joints for many years. On examination, she had a contracted left knee, moon face, and skin changes. Tests showed abnormal liver enzymes and blood sugar levels. She was diagnosed and treated with antibiotics, analgesics, corticosteroids, disease-modifying drugs, and hypoglycemic medications. Her third left toe was surgically removed due to gangrene. She was counseled on medication adherence and lifestyle changes.
David Moore, PhD, of UC San Diego HIV Neurobehavioral Research Program, presents "Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons"
Scott Letendre, MD, of the UC San Diego HIV Neurobehavioral Research Program, presents "Overview of HIV & Aging" for AIDS Clinical Rounds at UC San Diego
The document describes a pediatric case study of a 4-month-old male, Baby CG, born with Tetralogy of Fallot (TOF). Baby CG underwent various procedures including balloon valvuloplasty, angioplasty, and full TOF repair surgery. Baby CG's labs showed abnormalities including low oxygen levels and high glucose levels after surgery, which improved over time. The document also details Baby CG's medications, nutrition, and growth charts pre- and post-operatively.
This case presentation summarizes the case of a 16-year-old female patient diagnosed with systemic lupus erythromytous. She presented with rashes on her face, swelling in her lower limbs, fever, hair loss, and shortness of breath. Her medical history, examinations, lab tests, treatment and management are documented in detail over her hospital stay. She was diagnosed with SLE based on her symptoms and tests showing positive rheumatoid factor and meeting four diagnostic criteria. She was treated with medications and discharged with instructions to follow up in the outpatient clinic.
CASE PRESENTATION ON RHEUMATOID ARTHRITISBinuja S.S
A 57-year-old female was admitted with non-healing ulceration of the left ankle, edema of both lower limbs, and joint pain with intermittent fever. Her history and examinations were consistent with rheumatoid arthritis. She was treated with aspirin, prednisolone, methotrexate, folic acid, and other medications. Her joint pain and edema improved over her 6-day hospital stay, and she was discharged on medications with follow-up planned.
Mr. X, a 25-year-old male, presented with a high fever for one week and one episode of vomiting. His medical history included diabetes and hypertension. On examination, his temperature was 104 F, pulse was 102 beats/min, and blood pressure was 110/80 mm Hg. Laboratory tests confirmed paratyphoid A fever. He was diagnosed with paratyphoid A fever and treated intravenously with cefoperazone, sulbactam, pantoprazole, ondansetron, and ofloxacin. Upon discharge, he was advised to take paracetamol and pantoprazole tablets.
This document describes the case of a 51-year-old male labourer admitted with fever, facial puffiness, haematuria, epistaxis and leg swelling for 3-7 days. Investigations revealed cANCA positivity and renal involvement. A renal biopsy showed focal segmental glomerulonephritis with necrosis, consistent with ANCA vasculitis. A diagnosis of Wegener's granulomatosis was made based on renal and upper respiratory tract involvement. The patient was started on steroids and cyclophosphamide for treatment.
Dr. Saumya Agarwal presented a case of a 75-year-old female who was brought to the hospital semiconscious after a motor vehicle accident. She had a past medical history of diabetes, hypertension, and heart disease. Despite treatment for her injuries including a fracture of the right elbow and left shoulder, her condition deteriorated and she went into cardiac arrest. Resuscitation efforts were unsuccessful and she was declared dead due to cardiogenic shock resulting from her injuries sustained in the accident.
A 67 year old male patient was admitted to the male medicine ward with complaints of abdominal distension, bilateral lower limb oedema, pitting pedal oedema, distended and swelled scrotum and breathlessness since 15 days.
This document describes the case of a 55-year-old man who experienced episodes of sweating, shortness of breath, and diarrhea for 10 months. Imaging showed a mass in his jejunum, which was resected and found to be a carcinoid tumor. Carcinoid tumors are often associated with heart lesions due to secretion of vasoactive substances. The expected heart lesion in this case would be carcinoid heart disease, characterized by plaque-like lesions in the heart valves.
A 74-year-old African American female was admitted to the emergency department with signs of hypoglycemia, excessive anticoagulation, anemia, and infections. Laboratory tests found abnormal liver and kidney function along with hypothyroidism and rheumatoid arthritis. The patient received treatments including dextrose for hypoglycemia, antibiotics for infections, vitamin K to reverse anticoagulation, blood transfusions for anemia, and prognosis was poor due to multiple declining organ functions and infections.
CASE STUDY ON UTI AND OBSTRUCTIVE JAUNDICERajesh Dutta
A 63-year old female presented with abdominal pain, yellow urine, and burning urination. Lab work showed elevated liver enzymes and bilirubin consistent with obstructive jaundice. Imaging revealed gallstones obstructing the common bile duct, causing jaundice. She was diagnosed with urinary tract infection, obstructive jaundice, and gallstones. Treatment included antibiotics, antacids, and antispasmodics.
The document discusses several cases of glomerular disease:
1) A 27-year-old male with nephrotic syndrome and a kidney biopsy showing IgG and C3 deposits along the glomerular basement membrane consistent with membranous nephropathy.
2) A 78-year-old female admitted with nephrotic syndrome after a history of NSAID use, with a biopsy showing focal segmental glomerulosclerosis.
3) A 26-year-old male with nephrotic syndrome and renal impairment, whose biopsy demonstrated membranoproliferative glomerulonephritis with C3 deposition and subendothelial electron dense deposits. Follow up showed elevated
This document summarizes a patient mortality meeting discussing a 45-year-old female patient who was admitted unconscious following a road traffic accident. She sustained injuries including a laceration on her right thigh and eye, as well as an intertrochanteric fracture of the right femur. The summary outlines her hospital course, management including surgery, complications including infections, and eventual discharge on day 26 after addressing cerebral salt wasting.
Mr. Lee, a 59-year-old Chinese man, was admitted to the hospital for acute upper gastrointestinal bleeding due to rupture esophageal varices from cirrhosis of the liver and portal hypertension. He underwent band ligation of the esophageal varices during his admission and showed improvement. At discharge, he was advised to follow up in 2 weeks and annually for endoscopy surveillance due to his cirrhosis, continue medications and lifestyle modifications, and seek immediate medical care if symptoms return.
A 54-year-old male farmer presented with fever, body aches, and jaundice for several days. He worked in fields and around animals. On examination, he was febrile and tachycardic with irregular pulse. Tests found elevated liver enzymes and leptospira IgM antibodies. He was diagnosed with severe leptospirosis (Weil's disease) due to his occupation and exposure. He received antibiotics and supportive care and recovered within two weeks. Leptospirosis can mimic other diseases but a high index of suspicion is important for farmers and those exposed to animals or fields.
1. The document describes the rules and questions for the AIIMS MEDICINE QUIZ finals with 6 clinical rounds.
2. The rounds involve teams answering direct clinical case questions and having the option to "pounce" on other teams' questions for additional points.
3. Sample questions cover topics like pulmonary actinomycosis, milk-alkali syndrome, necrotizing migratory erythema, beri-beri, hepatic encephalopathy, NMO, and various cardiac conditions.
13. a case study on convulsions in a kco epilepsy with lactational amenorrhoeaDr. Ajita Sadhukhan
A 25 year old female patient was admitted to the female medicine ward with complaints of 2 and a half month amenorrhoea, epileptic fit convulsions at home, vertigo, generalised weakness and 1 episode of epileptic fit today evening.
This document summarizes the medical history and treatment of a 50-year-old male patient presenting with fluid overload, decreased urine output, and severe breathlessness. The patient had a history of diabetes, hypertension, chronic kidney disease, and other comorbidities. During his hospital stay, he received treatment including hemodialysis, antibiotics, and other medications. His condition initially improved but he then developed sepsis and died on January 18th while being transferred for another hemodialysis session.
The document discusses two conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). PNH is a complement-mediated hemolytic anemia treated with the drug eculizumab, a C5a inhibitor. aHUS is a complement-mediated thrombotic microangiopathy that can cause stroke, heart attack, and kidney failure, and is also treated with eculizumab. The document asks the reader to identify PNH, aHUS, and the mode of action of eculizumab.
Case presentation on gastroenteritis and acute renal failureDr P Deepak
A 42-year old female patient presented with gastroenteritis and acute renal failure. She reported loose stools and vomiting for several days. Laboratory tests found elevated urea and creatinine levels indicating acute renal failure. She was diagnosed with acute gastroenteritis caused by Entamoeba histolytica and treated with intravenous antibiotics, antiemetics, and proton pump inhibitors. Her condition improved over the next few days with reduced vomiting and stool frequency.
A 48-year-old female presented with left foot gangrene, drug-induced Cushing's syndrome, rheumatoid arthritis, and type 2 diabetes. She reported pain and swelling in her lower limbs and joints for many years. On examination, she had a contracted left knee, moon face, and skin changes. Tests showed abnormal liver enzymes and blood sugar levels. She was diagnosed and treated with antibiotics, analgesics, corticosteroids, disease-modifying drugs, and hypoglycemic medications. Her third left toe was surgically removed due to gangrene. She was counseled on medication adherence and lifestyle changes.
David Moore, PhD, of UC San Diego HIV Neurobehavioral Research Program, presents "Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons"
Scott Letendre, MD, of the UC San Diego HIV Neurobehavioral Research Program, presents "Overview of HIV & Aging" for AIDS Clinical Rounds at UC San Diego
Theodoros Katsivas, MD of UC San Diego Owen Clinic and Jill Blumenthal, MD of UC San Diego AntiViral Research Center present, "Revisiting MAC in the IRIS Era: Clinical Case and Discussion"
Edward R. Cachay, MD, MAS of UC San Diego Owen Clinic presents "When to Consider Neurosurgical Interventions for the Management of Complicated Cryptococcal Meningitis"
Tyler Lonergan, MD, of the UC San Diego Owen Clinic, presents "Stemming the Tide of Cardiovascular Disease: Transitioning from OI to CVD Prophylaxis" for AIDS Clinical Rounds at UC San Diego
Clinical Professor
UC San Diego Owen Clinic
Francesca Torriani, M.D., of UC San Diego Owen Clinicm, presents "Update on International CFAR Grant on Tuberculosis and HIV Screening in Healthcare Workers at Maputo Central Hospital in Mozambique" at AIDS Clinical Rounds
1) Modern antiretroviral treatment has increased life expectancy for HIV-positive patients, resulting in more presenting for elective and emergency orthopaedic surgery.
2) HIV-positive patients can experience various musculoskeletal manifestations including bone disorders, joint diseases, myopathies, and neoplasms. Common conditions include osteomyelitis, osteonecrosis, septic arthritis, and Kaposi sarcoma.
3) Outcomes for procedures like joint replacements and fracture treatments in HIV-positive patients have been found to be comparable to HIV-negative patients when considering infection and complication rates, with some increased risk for certain patient subgroups or procedures. Overall management requires consideration of individual factors like CD4 count and viral load
A radiological insight into various musculoskeletal complications in patients suffering from AIDS and how it'll affect the management of the patient. A must know for all Radiologists.
This document discusses HIV and its effects in orthopaedics. It provides statistics on HIV deaths and hospitalizations. It describes the structure and life cycle of the HIV virus, how it attacks the immune system, and the stages of HIV infection. It discusses various orthopaedic problems seen in HIV patients like arthritis and fractures. It also outlines strategies to diagnose and manage HIV, including antiretroviral drug therapies, and precautions orthopaedic surgeons should take when operating on HIV patients.
1. The document discusses skeletal manifestations in HIV infected patients, including reactive arthritis, Reiter's syndrome, psoriatic arthritis, septic arthritis, HIV-associated arthropathy, and painful articular syndrome.
2. It covers the classification and definition of HIV/AIDS according to the CDC and WHO, including disease progression, opportunistic infections, and CD4 cell counts.
3. The epidemiology of HIV is examined, including transmission routes between people of different ages, from mother to child, and occupational transmission among healthcare workers.
This document discusses bone tumors. It defines bone tumors and divides them into primary and secondary tumors. Primary bone tumors are rare, accounting for 0.2% of adult and 5% of childhood cancers. The document describes the typical characteristics, locations, and most common types of both primary bone tumors and secondary bone metastases. It outlines the clinical features, diagnostic imaging, laboratory investigations, biopsy, staging, and management of bone tumors.
Kaposi Sarcoma is an intermediate grade tumor that is rare in the general population but commonly seen in AIDS patients. There are four types of Kaposi Sarcoma: chronic, lymphadenopathic, transplant-associated, and AIDS-associated. Kaposi Sarcoma is caused by infection of endothelial cells by the KSHV virus, which causes lytic and latent infection and leads to abnormal cell proliferation through cytokine production and disruption of normal cell growth regulation, resulting in the clinical manifestations of Kaposi Sarcoma such as macules, patches, and violaceous plaques and nodules. Treatment options include surgery, radiation, chemotherapy, antiretroviral drugs, IFN-A, and angiogenesis inhibitors.
This document discusses surgical jaundice, defined as jaundice that can be treated surgically, usually due to extrahepatic biliary obstruction. It covers the definition, causes, pathophysiology, clinical evaluation and treatment of surgical jaundice. The most common cause is gallstones, which can become lodged in the common bile duct. Physical examination may reveal jaundice and abdominal tenderness. Imaging studies can locate the obstruction and determine if it is intrahepatic or extrahepatic. Treatment involves addressing the underlying cause, often through surgery such as cholecystectomy for gallstones or bypass procedures for cancer.
This document discusses obstructive jaundice, including a case study of an 82-year-old male patient presenting with progressive jaundice, itching, weight loss, and other symptoms. It reviews the causes, pathophysiology, investigations, and management of obstructive jaundice. Common causes include gallstones, pancreatic cancer, and cholangiocarcinoma. Investigations may include blood tests, ultrasound, CT, MRCP, and ERCP. Management depends on the underlying cause but may involve surgical procedures like cholecystectomy, Whipple procedure, or stenting to relieve the obstruction.
This document provides an overview of malignant bone tumors, including their classification, occurrence, imaging appearance, and examples. It discusses several primary malignant bone tumors in detail, including osteosarcoma and multiple myeloma. Osteosarcoma most commonly affects teenagers and young adults, presents as aggressive bone destruction with periosteal reaction on x-ray, and has variable appearances on MRI/CT. Multiple myeloma commonly affects older adults, causes lytic lesions scattered throughout the skeleton appearing as "punched out" areas on x-ray, and MRI is most sensitive for detecting its bone involvement. The document outlines radiographic features that can help characterize and differentiate various malignant bone tumors.
1. The document discusses the classification, diagnosis, and imaging appearances of various bone tumors and tumor-like lesions.
2. Key bone tumors discussed include osteosarcoma, giant cell tumor, and bone cyst. Osteosarcoma is classified based on X-ray signs into osteosclerotic, osteolytic, or mixed types.
3. Imaging findings help determine if a bone lesion is benign or malignant based on characteristics such as boundaries, destruction pattern, periosteal reaction, and surrounding soft tissues.
This document discusses the radiological approach to evaluating bone tumors. Key points include:
1) The goals are to not overtreat benign tumors, undertreat malignant tumors, or misdirect biopsies.
2) Location, age of patient, characteristics of the tumor such as matrix and borders can help narrow the differential diagnosis.
3) A systematic evaluation of plain radiographs considers features like zone of transition, periosteal reaction, and presence of mineralized matrix to characterize the tumor.
The document discusses bone tumors. It begins by stating that the most common bone tumor is secondary tumors from other sites, while the most common primary bone tumor is multiple myeloma. It then covers the WHO classification of bone tumors including bone-forming, cartilage-forming, marrow, vascular, and other tumors. Diagnosis involves clinical examination, imaging like radiographs, CT, MRI and bone scans, as well as laboratory tests and biopsy. Staging is discussed including the Enneking system based on aggressiveness and spread. Management depends on staging and includes wide excision for low grade lesions and more radical resection or palliative treatment for high grade or metastatic tumors.
(1) Head and neck swellings can have many causes, including lymph node enlargement, cysts, infections, benign and malignant tumors. (2) While some masses are cancerous, many are non-cancerous cysts or enlarged lymph nodes. (3) Evaluation of persistent or enlarging lumps involves medical history, physical exam, and may include imaging tests and biopsy to determine if surgical removal or other treatment is needed.
Anti-Phospholipid Syndrome Grand Round Presentation Dhaka Medical College Hos...Mohammed Shadman Shakib
A case of 20 year female presenting with fever, respiratory distress and joint pain.This case was presented in grand round session of Department of Medicine , Dhaka Medical College Hospital on 6th July, 2019.
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
Clinical Scenario:
REASON FOR CONSULTATION:
Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional:
Negative for diaphoresis and chills.
Positive for fever and fatigue.
HEENT:
Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Positive for throat pain secondary to her laryngeal cancer.
Eyes:
Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory:
Positive for cough and shortness of breath
. Negative for hemoptysis and wheezing.
Cardiovascular:
Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal:
Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary:
Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal:
Negative for myalgias, back pain and falls.
Skin:
Negative for itching and rash.
Neurological:
Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies:
Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric:
Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric.
A 30-year-old male presented with jaundice, vomiting, fatigue and oliguria for 4 days. On examination, he had pallor, icterus, hepatomegaly and altered sensorium. Investigations revealed macrocytic anemia, elevated liver enzymes and kidney dysfunction. A kidney biopsy showed fibrin thrombi in renal capillaries. He was diagnosed with atypical hemolytic uremic syndrome (aHUS) based on the clinical features and biopsy findings. aHUS has a poor prognosis with mortality rates up to 25% and 50% of patients progressing to end-stage renal disease.
This document presents a case study of a 56-year-old man with type 2 diabetes presenting with a non-healing ulcer on his right foot following toe amputation. It provides details of his medical history, examination findings, lab investigations, and discusses diabetic foot ulcers and complications. The key points are:
1) The patient had type 2 diabetes for 10 years and was non-compliant with medication, presenting with a non-healing ulcer on his right foot post amputation of toes.
2) Examination found an irregular ulcer on his right foot with signs of infection. Investigations showed renal dysfunction and hyperglycemia.
3) Diabetic foot ulcers are a major complication
This document presents the case of a 55-year-old female admitted with acute pancreatitis. She has a history of recurrent epigastric pain and was previously treated for suspected acute cholecystitis. On current admission, she has epigastric tenderness and elevated lipase. Imaging reveals no gallstones but incidental pneumonia. She is managed supportively with IV fluids and analgesics. Her symptoms and labs improve and she is discharged on a soft diet. The document reviews the etiology, pathogenesis, diagnosis, assessment of severity, management considerations, and follow-up care for acute pancreatitis.
Case presentation on Cerebrovascular accident (Stroke)HAMMADKC
This document presents a case report of a 76-year-old male patient admitted to the neurology department with complaints of forgetting, left hand weakness, slurred speech, and incontinence. The patient has a history of hypertension, previous cerebrovascular accident, and fall from bed. Examination and investigations including MRI and angiogram confirmed the diagnosis of cerebrovascular accident. The patient was treated with medications like citicoline, levetiracetam, atorvastatin, and aspirin. His condition improved and he was discharged with advice on medications and lifestyle modifications to prevent further strokes.
The document describes a case report of an 80-year-old male who presented with abdominal pain for 4 days. On examination, he had tenderness in the epigastric and right upper quadrant regions. Laboratory tests showed elevated lipase, amylase and CRP, consistent with acute pancreatitis. CT imaging revealed a relatively enlarged pancreas. He was admitted and treated supportively with IV fluids, antibiotics and pain medications. His condition gradually improved and he was discharged. Common scoring systems for evaluating severity of acute pancreatitis like Ranson's criteria and BISAP score are discussed.
1. A 35-year-old man presented with acute onset of breathlessness and was found to have pulmonary thromboembolism and deficiencies in protein C and protein S without evidence of deep vein thrombosis.
2. He was treated with supportive measures, heparin, acenocoumarol, and supplements but developed massive hemoptysis and succumbed to his illness despite intensive care.
3. The case report discusses evaluation, treatment, and long-term management of venous thromboembolism and highlights complications that can arise.
A 44-year-old woman with a history of gestational diabetes, obesity, and hypertriglyceridemia presented to the emergency room with abdominal pain. CT scan showed inflammatory changes in the pancreas consistent with acute pancreatitis. Laboratory work showed very high triglycerides of over 14,000, blood glucose of 320, and HbA1c of 10.1, indicating long-standing uncontrolled diabetes. She was admitted to the ICU for treatment of pancreatitis, diabetic ketoacidosis, acute renal failure, and hypocalcemia. Through intensive insulin treatment and diet modification in the hospital, her triglycerides and diabetes control improved substantially.
CASE PRESENTATION : PYREXIA OF UNKNOWN ORIGIN / Hemophagocytic lymphohistioc...Dr. Darayus P. Gazder
A 71-year-old male presented with 2 months of fever, headaches, and weight loss. Initial workup revealed anemia, elevated liver enzymes and inflammatory markers. He was treated for enteric fever but did not improve. Further testing showed pancytopenia, a weakly positive ANA, and a bone marrow biopsy suggestive of granulomas. He developed cough and hypoxemia. Imaging found pleural effusions and lung consolidation. The working diagnosis shifted to tuberculosis given suggestive bone marrow findings. Treatment with antitubercular therapy and steroids was started.
- A 52-year-old female presented with a 1-month history of cough and fevers after being treated for breast cancer. She was admitted to the hospital with worsening shortness of breath.
- On admission, she had abnormal lab results including elevated white blood cell count. A chest CT showed abnormalities. Antibiotics were started but she continued to spike fevers.
- Sputum cultures grew gram-positive cocci. Bronchoscopy with biopsy showed inflammatory infiltrate but did not reveal a definitive diagnosis. Further diagnostic testing was done on hospital day 5.
This document presents a case study of a 43-year-old man presenting with vomiting and abdominal pain. Through examination and investigations, he was found to have chronic liver disease complicated by cirrhosis and hepatorenal syndrome. He was treated with antibiotics and medications for his liver conditions. Literature review discussed decompensated liver disease including definition, epidemiology, etiology, pathophysiology, clinical features, investigations and management. The case study followed the patient's hospital course and changing diagnosis and treatment over time.
A 50-year-old male was admitted with swelling of the lower limbs, fever, chills, vomiting, and diarrhea. He has a history of chronic kidney disease and malaria. On examination, he was febrile and had pallor, icterus, and tenderness in the abdomen. Laboratory tests showed decreased hemoglobin and kidney function. He was diagnosed with chronic kidney disease exacerbation and malaria and treated with IV fluids, antibiotics, antimalarials, and other medications. His condition improved and he was discharged on medications including antibiotics and supplements with counseling on diet, lifestyle and medication adherence.
Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular AccidentDJ CrissCross
The document presents a case study of a 20-year-old male who developed acute renal failure secondary to rhabdomyolysis caused by a motorcycle accident. He was admitted with abdominal pain and distension. His creatinine levels increased significantly over his hospital stay, indicating acute kidney injury. He received various treatments including IV fluids, medications, and multiple hemodialysis sessions. His condition gradually improved and he was discharged after three weeks with instructions for outpatient follow up and medication.
This document discusses considerations for liver transplantation including:
1. Evaluating a patient's need, safety, ability to comply, and quality of life for transplant eligibility.
2. Assessing donor liver fitness including medical history, lab tests, and biopsy.
3. Managing a patient's care while waiting for transplant including preventing complications.
4. Evaluating potential causes for graft dysfunction after transplant such as rejection or other issues.
A 17-year-old female presented with seizures for the past 6 months. On examination, she was found to have hypocalcemia with a serum calcium level of 5.7 mg/dl. Further workup revealed low levels of parathyroid hormone, indicating hypoparathyroidism as the cause of her hypocalcemia and seizures. Brain CT and EEG were normal. She was started on calcium and vitamin D supplementation, which improved her symptoms and lab abnormalities.
Inpatient Case Presentation. Kyle CriscoKyle Crisco
Kyle Crisco is a 37-year-old male with cerebral palsy and seizures who was admitted for sepsis. He developed systemic inflammatory response syndrome with respiratory failure and was started on broad-spectrum antibiotics. Imaging showed consolidation in his right lung base consistent with healthcare-associated pneumonia. Blood cultures grew methicillin-resistant Staphylococcus aureus. The patient was treated with vancomycin, piperacillin-tazobactam, and other supportive medications. After 5 days of antibiotics and becoming afebrile and clinically stable, vancomycin was stopped. The patient's prolonged hospital stay was complicated by intermittent emesis from a feeding tube, which resolved after tube replacement.
Similar to An Unusual Presentation of a Known HIV Related Condition Presenting as a Septic Mimic (20)
Katherine Promer Flores, MD (she/her)
Staff Physician
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Maile Young Karris, MD
Associate Professor
Co-Director San Diego Center for AIDS Research Clinical Investigations Core
Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology
Department of Medicine
University of California San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Gabriel Wagner, MD
Associate Clinical Professor
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
This presentation summarizes research on cryptococcal antigen screening and treatment in resource-limited settings. It finds that screening individuals with CD4 counts <100 cells/uL and <200 cells/uL can reduce mortality, and point-of-care tests now enable screening in primary care clinics. Studies of simplified treatment regimens show promise, such as using high-dose liposomal amphotericin B for only 1-2 weeks. Field work in Mozambique demonstrated a 7.3% prevalence of cryptococcal antigenemia through screening at two clinics, and identified opportunities to improve care through expanded screening and ambulatory treatment models.
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Este documento fornece informações sobre uma sessão de treinamento virtual sobre HIV/AIDS para militares internacionais. A agenda inclui atualizações sobre a vacina COVID-19 e sua implementação na Nigéria, com discussões sobre implicações para pessoas vivendo com HIV. A sessão é conduzida pelo programa MIHTP-ECHO com o objetivo de melhorar o atendimento e prevenção de HIV em militares em todo o mundo.
This document provides information about a MIHTP-ECHO training session on COVID-19 vaccines. It includes the agenda, presenters, and an overview of MIHTP and the ECHO model. The presentation by Dr. Allen McCutchan will discuss COVID epidemiology, vaccine mechanisms of action, effectiveness, safety, and duration of protection. It will also cover implications for people living with HIV and emerging variants. A presentation by Captain UO Adekanye will provide an update on Nigeria's COVID vaccine rollout and implications for people living with HIV. The session aims to inform participants and facilitate discussion on these topics.
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Davey Smith, MD, MAS
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Chief, Division of Infectious Diseases and Global Public Health
Co-Director, San Diego Center for AIDS Research (CFAR)
Department of Medicine
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Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Darcy Wooten, MD
Assistant Professor of Medicine
Associate Program Director, Infectious Diseases Fellowship
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
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Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
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Treatment Options
Endocrine Therapy
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Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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Public Health Lecture 4 Social Sciences and Public Health
An Unusual Presentation of a Known HIV Related Condition Presenting as a Septic Mimic
1. M I C H A E L K A V A N A U G H
A P R I L 4 , 2 0 1 4
AIDS CLINICAL ROUNDS
2. Disclosures
I have no relevant financial relationships with any
commercial supporters.
Unlabeled/Investigational products and/or services
will be mentioned in this CME offering.
3. 67 y/o Caucasian man with
HIV/AIDS, OCT CD4+
437/14%/VL undetectable who
presents to NMCSD ER with
complaint of progressive dyspnea
and a mild dry cough for the last 7
days
4. History Continued
Initially, his dyspnea was with stairs
Progressed to flat surfaces
Baseline can walk a few miles, dyspnea with 1 city block and
then at time of admission at rest for past 1-2 days
Dry cough for 7 days-no sputum or hemoptysis
10 lb weight loss over last 6 weeks
Denies any fevers
Reports that his home blood pressures have been low
(systolic in 80s) so he stopped taking Lisinopril
5. Review of Systems
Constitution-no fevers or chills, +fatigue
HEENT-no sinus tenderness or rhinorrhea
Chest-one episode of substernal chest pain 4 days prior to
admission-none at present, no palpitations
Resp-DOE – now at rest shortness of breath, slight dry cough,
no sputum
GI-no abdominal pain, baseline chronic diarrhea-slight
improvement recently
GU-increased nocturia (baseline 1x/night, now 4x/night over
last 4 week)
MSK-Significant improvement in shoulder function after
steroid injection in December
Neuro-noncontributory
6. PMH
HIV+; dx oct2006-presented with
AIDS with PCP and was admitted
with respiratory distress, requiring
corticosteroid therapy which
resulted in a flare of KS
Currently undetectable on
Truvada/Atazanavir/ritonavir/Raltegr
avir
Switched from Kaletra/Truvada to
RAL/3tc/Ataz/Rit on 16sep 2012,
previously on Atripla for short period
Genotype 10/12/06: PI mutations:
I13V, M36L, L63P; no clinical
resistance
Kaposi Sarcoma s/p systemic
chemotherapy (doxorubicin)-
Jan07-Nov07
Cryptosporidium-treated with
nitazoxanide Sept10
BPH
HLD
Left Shoulder tendonitis-steroid
injection Dec 2013
HTN
C diff-oct06
PCP-oct06; based on BAL giemsa
CKD (GFR 50)
ED
Stage I diastolic dysfunction
3rd degree AV block s/p
pacemaker--2007, pacemaker
recently checked OS PVD-jul07
B12 def.
gynecomastia
SCC L ear s/p MOHS-2008
L ear AK cryotherapy-Dec10
?ABC hypersensitivity-Jul08
Diarrhea predominant IBS-since
age 45; prior significant diarrhea
while on Kaletra
7. Medical History continued
MEDS
Truvada
Raltegravir 400mg bid
Atazanavir 300mg daily
Ritonavir 100mg daily
Uroxatral 10mg qd
Lipitor 20mg qhs
Synthroid 75
Lisinopril 5mg-held for 1 day
Fish oil 2 pills (1200mg) qam
ASA 81mg qd
MVI (Ocuvite)
Allergies-Sulfa
Past Surgical History
Cholecystectomy 2009
Septoplasty
Skin excision for SCC
Shoulder injection (Dec 2013)
Social History
Married-lives with wife
Nonsmoker, No alcohol
Retired Navy MCPO
8. Exposure History
Travel: No travel outside US since 2006
Animals: 2 dogs
Food Exposure: noncontributory
Soil Exposure: occasional gardening in home, does
not wear a mask
Other: Denies sick contacts
9. Physical Exam
T98.3 P94 R16 BP 132/72 99% RA wt 56 kg
GEN: NAD, A&Ox4, WDWN
HEENT: PERRL, EOMI, nl sclera, no photophobia, no throat inflammation.
NECK: nl thyroid, no neck masses, no JVD
HEART: RRR S1/S2, no M/G/R
LUNGS: CTA Bilaterally
ABD: Soft NT/ND, +BS, no HSM
LYMPHATICS: No LE edema, no axillary, groin, neck adenopathy.
EXT: No LE edema
MUSCULOSKELETAL: no joint effusions or pain, no muscle tenderness
DERM: Actinic keratoses on right cheek & on his forehead, also with 2 mm of purple
hyperpigmentation on right cheek. No lesions or sores visible elsewhere. (+) for
hyperpigmentation on right forearm from prior Kaposi's sarcoma
NEURO: CN 2-12 grossly intact, no focal deficits
PSYCH: no perceived mood disorder, nl demeanor with appropriate behavior.
LINES/DEVICES: Clean without signs of infection
10. Labs/Radiology
CBC 4.9/11.3/33.2/181 N77.4 L16.5
Lytes 131/3.6/93/26/31/1.3/200 Ca 8.9 Mg 2 P 2.1
AST 16 ALT 20 Alk P 68
T bili 2.6
Alb 3.6 total protein 6.5
14. Hospital Course
CT Chest performed-negative
ECG and cardiac enzymes unremarkable
No antibiotics provided
No bronchoscopy performed
Diagnosed with a URI?
Also diagnosed with new onset DM-HbA1C 6.6
Diabetic teaching provided
No medications initiated
Held Lisinopril as possible source of cough
Fatigue improved without significant intervention
15. Clinic Follow up
Patient reports feeling very well
Walking 1-2 miles per day
Nocturia has returned to 1x per night (baseline)
Diarrhea has remained – actually improved over last 2 months
Shoulder feels very well
Afebrile
No cough or SOB
Blood Pressures off Lisinopril 120s-130s
Blood Sugars in 130-166
17. Another Comparable Case
50 year old male with HIV+ CD4
503/13% VL undetectable, on
Truvada, atazanavir/ritonavir
(RV168 protocol patient), prior KS
(Jan 2012) treated with radiation
presents for clinic follow-up with 20
lb weight loss over last 6 months
18. Pertinent History
Patient had intra-articular steroid injection (Aug
2013)-kenalog in left shoulder (2 years shoulder pain)
Developed fatigue, shakiness and drenching night sweats
without fevers
Wasting of arms and legs
Dyspnea on exertion
Abdominal bloating
Increased urinary frequency (3x nocturia)
A1C increased from 6.3->7 in one month-post-prandial glucose
180
Lost 15 lbs in 4-6 weeks
New skin lesions requiring surgical removal
19. Pertinent History Continued
At time-period annotated on previous, he had a
recent decrease in CD4 from 504/19% to 214/11%
Started on TMP/SMX
Weight loss, change in CD4, history of KS & new skin lesions
Concern of recurrence
Bloating sensation with weight loss
Received cholecystectomy
Adrenal insufficiency was “ruled out” by primary
care provider
20. Past Medical History
HIV diagnosed 1996 –
genotype 2001 M184V,
K103R, L63, M36
Headache syndrome
Depression
Allergic rhinitis
Kaposi’s sarcoma Jan 2012
Radiation x 10
BPH s/p TURP
Herpes
Resolved hepatitis B
FHx
Family medical history:
Diabetes-maternal side
Breast CA maternal aunt
PSH
PRK
R inguinal hernia repair
TURP-1999
Cholecystectomy – Sep 13
Septoplasty
NKDA
Social History
Denies tobacco
+ EtOH 4X/week
Denies ilicits
Currently in monogamous
relationship, partner is
seronegative
Works in health systems
management
21. Medications
Atazanavir 300mg po daily
Ritonavir 100mg po daily
Truvada (tenofovir 300mg +Emtricitabine 200mg)
po daily
Fexofenadine 60mg po bid
Atorvastatin 20mg po daily
Escitalopram 10mg po daily
Sumitriptan prn
Hydrocortisone
TMP/SMX
22. Physical Exam
T99.2 BP 134/86 P98 R14
Gen well appearing
Head-cushingoid with moon like facies
Neck-increased fat on posterior neck and upper back
Oral cavity normal
Lymph nodes-no abnormalities noted
Lungs cta (b)
CV RRR no murmur
Abd +bs, soft, NT, ND, well healed surgical scars
Musculoskeletal-arm thinning (b)
Neuro CN II-XII intact
Skin scattered purple plaques on arms, legs and bilateral feet
23. Evaluation
CBC 8.1/14.2/42.4/222 N 45.9 L 46.3 E 0.7
Lytes 144/3.6/105/23/10/0.9/104 Ca 8.4 Mg 2.3
Bili 2.1 Prot 6.5
Alk P 52 ALT 43 AST 26
UA SG 1.017 protein neg, gluc neg, pH 6
Skin lesions evaluated by dermatology including bx
Negative for KS
24. AM Cortisol
Cortisol AM Site/Specimen 03 Oct 2013 0910
Cortisol AM SERUM 9.760 <o> mcg/dL
(6.2-19.4)
Cortisol AM Site/Specimen 03 Oct 2013 0840
Cortisol AM SERUM 7.210 <o> mcg/dL
(6.2-19.4)
Cortisol AM Site/Specimen 03 Oct 2013 0800
Cortisol AM SERUM 0.778 (L) <o>mcg/dL
(6.2-19.4)
25. Additional Labs
Thyroxine free 1.2 nl
HBA1C 7 (previous 6.3)
Liver enzymes (September) Alk P 213 ALT 162 AST
33 T bili 2.73 with dbili 0.35
26. Course continued
As steroid level waned-fatigue worsened
Endocrine consult-Diagnosed with Cushing’s
Syndrome with secondary adrenal insufficiency
Started on hydrocortisone with taper
Recognized that ritonavir may be issue
Checked ACTH-low nml 8 (6-50 pg/mL)
MRI brain- nondiagnostic
Performed cosyntropin stimulation test normal
(7.94->19) in one hour, stopped hydrocortisone
27. Which of the following is an appropriate
screening test for Cushing’s Syndrome?
Urine Cortisol
Urine Metanephrines
Salivary Metanephrines
Cosyntropin (ACTH) stimulation test
Serum Metanephrines
28. Which of the following is an appropriate
screening test for Cushing’s Syndrome?
Urine Cortisol
Confirmatory with Dexamethasone suppression test
Urine Metanephrines
Salivary Metanephrines
Cosyntropin (ACTH) stimulation test
Serum Metanephrines
29. Cushing’s Syndrome
Iatrogenic hypercortisolism (most common)
Ingested/injected/topical/inhaled steroids & megestrol acetate
Ectopic ACTH syndrome- 20 to small cell lung cancer
or adrenal tumors
Cushing’s Disease-pituitary ACTH source
Factitious Cushing’s- surreptitious intake of steroids
Hypercortisolism can occur
Extreme stress (including sepsis)
Obesity and polycystic ovary syndrome
Severe prolonged major depressive disorder
Chronic alcoholism
30. Clinical Manifestations
Progressive Central obesity
Children with generalized obesity and growth retardation
Facial Fat accumulation “Moon facies”
Buffalo hump
Skin atrophy
Easy bruisability
Striae
Fungal infections
Hyperpigmentation-induced by increased ACTH (not
cortisol)-binds melanocyte-stimulating hormone
Menstrual irregularities
Proximal muscle wasting –catabolism
Bone loss-can result in pathological fractures
32. Manifestations continued
Glucose intolerance
Stimulation of gluconeogenesis by cortisol & peripheral insulin
resistance
Hyperglycemia in 10-15% of patients
Cardiovascular disease
Increased risk of MI and Stroke
Hypertension
Thromboembolic disease
Neuropsychiatric (labile, depressed, anxiety, panic
attacks)
Increased frequency of Infections-inhibited immune
system
Ophthalmologic findings-increased IOP & cataracts
33. Test for Cushing’s Syndrome
Daily urinary cortisol (24 hours best)
10 pm-8 am is acceptable alternative
Late evening salivary cortisol-only beneficial if
extremely elevated
Low dose dexamethasone suppression test
Should suppress ACTH and subsequently reduce urine cortisol
34. Test of Adrenal Insufficiency
Morning cortisol level
> 11 ug/dL not adrenal suppression
<3 ug/dL adrenal suppression
Follow up study is cosyntropin (ACTH) stimulation test
35. Although idiopathic adrenal insufficiency in HIV is rare, what
percentage of post-mortem evaluations of the adrenal gland
are abnormal?
<5%
10%
25%
33%
66%
36. Although idiopathic adrenal insufficiency in HIV is rare, what
percentage of post-mortem evaluations of the adrenal gland
are abnormal?
<5%
10%
25%
33%
66%-common sources include CMV,
Mycobacteria tuberculosis, Histoplasmosis,
PCP, Toxoplasmosis and Kaposi’s Sarcoma
37. Adrenal Function in HIV
Higher basal cortisol & lower dehydroepiandrosterone
Overt adrenal insufficiency is uncommon
Hypercortisolism in the absence of Cushings
No treatment required
Hypocortisolism always requires treatment
38. Comparison with Lypodystrophy with PIs
“pseudo Cushings”
Altered body adipose tissue
Truncal obesity
Peripheral wasting
Breast hypertrophy
“Buffalo hump”
Insulin hypersensitivity
Normal cortisol and normal dexamethasone
suppression tests
Lack striae and easy bruisability
39. When combined with corticosteroids, which medication has
been reported to be a contributing factor in iatrogenic
Cushing’s Syndrome?
Etravirine
Ritonavir
Zidovudine
Tenofovir
Emtricitabine
40. When combined with corticosteroids, which medication has
been reported to be a contributing factor in iatrogenic
Cushing’s Syndrome?
Etravirine
Ritonavir
Zidovudine
Tenofovir
Emtricitabine
41. Ritonavir and Clearance of Steroids
Iatrogenic Cushing’s Syndrome with
Osteoporosis and Secondary Adrenal Failure
in Human Immunodeficiency Virus-Infected
Patients Receiving Inhaled Corticosteroids
and Ritonavir-Boosted Protease Inhibitors:
Six Cases
Samaras, K, Pett S, Gowers, A et al. J Clin Endo and
Metabolism 2005.
Review in 2008 reported 25 cases at that date of
ritonavir and fluticasone combination
42. Clearance of steroids can be delayed by PI
including ritonavir
6 patients reported to develop iatrogenic Cushings
following inhaled fluticasone for asthma
Adrenal suppression noted in all 6 patients
When fluticasone removed-4/6 developed hypocortisolism
3/6 developed osteoporosis with pathological fx (1/6)
Exacerbation of DM (1/6)
These patients had prior lipodystrophy delaying
diagnosis
Fluticasone is lipophilic-prior lipodystrophy may contribute
Wide range of variability of 24-hour urine free cortisol
levels
Suppressed is suppressed
Remained suppressed for > 5 months
44. Cushing’s syndrome with adrenal suppression induced by inhaled
budesonide due to a ritonavir drug interaction with a woman with
HIV infection. Yoganthan K et al. 2011 Int J STD and AIDS
48 year old HIV+ woman with CD4 812 VL undetectable
on darunavir/ritonavir emtricatabine and efavirenz (stable
regimen for 3 years) presented with cushingoid features
after taking inhaled budesonide for 18 months
Iatrogenic Cushings w/ secondary adrenal suppression
After cortisols resolved, Cushingoid habitus remained
2010-Prior reported case of budesonide & PIs resulting in
Cushings in 37 year old African woman
Budesonide, beclomethasone & triamcinolone
recommended as safer options
Fluticasone longest half life and most lipophilic
45. Iatrogenic Cushing’s syndrome after intra-articular
triamcinolone in a patient receiving ritonavir-boosted
darunavir Hall JJ et al. 2013 Int J STD & AIDS
Triamcinololone is metabolized by CYP3A4
Ritonavir has greatest effect on CYP3A4 of the PIs
Case: 53 year old woman on darunavir/r who
developed cushinoid symptoms 2 weeks after
receiving single triamcinolone dose in left shoulder
Triamcinolone injection (both intra-articular and
epidural) related Cushing’s Syndrome has been
reported previously (usual dose 40-80 mg)
Follow on HPA axis suppression usually 2-6 months
No reports with cobicistat-but significant CYP3A4
47. Which of the following is the most sensitive test
for diagnosis of glucocorticoid induced diabetes?
Random plasma glucose >200 mg/dl
75 g oral glucose tolerance test (2 hour value)> 150
Fasting plasma glucose>126
Hemoglobin A1C>6.5%
48. Which of the following is the most sensitive test
for diagnosis of glucocorticoid induced diabetes?
Random plasma glucose >200 mg/dl
75 g oral glucose tolerance test (2 hour value)> 150
Fasting plasma glucose>126
Hemoglobin A1C>6.5%
49. Glucocorticoid Induced Diabetes and Adrenal
Suppression
Lansang MC, Hustak L. Glucocorticoid-induced diabetes and
adrenal suppresion: How to detect and manage them. Cleveland
Clinic Journal of Medicine. 2011: 78: 748-756.
9% of patients with RA develop DM within 2 years of steroids
All types of glucocorticoid formulations including eye drops
Mechanism is insulin resistance in liver
Peak effect 4-6 hours after dose
Symptoms (either iatrogenic diabetes or Cushing’s) less likely
if regimen mimics physiology (diurnal variation)
Insufficiency (Addison’s)-failure of adrenals or pituitary
51. Early diagnosis and treatment of steroid-induced diabetes mellitus
in patients with rheumatoid arthritis and other connective tissue
diseases. Ito S et al. Modern Rheumatology 2014.
Mechanism-augmentation of hepatic
gluconeogenesis & inhibition of glucose uptake in
adipose tissue
Since steroids are administered in am, most
hyperglycemia is afternoon post-prandial
Author recommended dividing steroid dosing
52. References
http://www.uptodate.com/contents/establishing-the-diagnosis-of-cushings-
syndrome?source=search_result&search=cushings&selectedTitle=1%7E150 Accessioned 31
March 2014
http://www.uptodate.com/contents/epidemiology-and-clinical-manifestations-of-cushings-
syndrome?source=search_result&search=cushings&selectedTitle=2%7E150 Accessioned 31
March 2014
Samaras, K, Pett S, Gowers, A et al. Iatrogenic Cushing’s Syndrome with Osteoporosis and Secondary Adrenal Failure in
Human Immunodeficiency Virus-Infected Patients Receiving Inhaled Corticosteroids and Ritonavir-Boosted Protease
Inhibitors: Six Cases. J Clin Endo and Metabolism 2005: 90:2005-36.
Lansang MC, Hustak L. Glucocorticoid-induced diabetes and adrenal suppresion: Howe to detect and manage them.
Cleveland Clinic Journal of Medicine. 2011: 78: 748-756.
Yoganthan K et al. Cushing’s syndrome with adrenal suppression induced by inhaled
budesonide due to a ritonavir drug interaction with a woman with HIV infection. Int J STD and
AIDS. 2011:23:520-521.
Hall JJ et al. Iatrogenic Cushing’s syndrome after intra-articular triamcinolone in a patient
receiving ritonavir-boosted darunavir. Int J STD & AIDS. 2013: 24:748-756.
Ito S et al. Early diagnosis and treatment of steroid-induced diabetes mellitus in patients with
rheumatoid arthritis and other connective tissue diseases. Modern Rheumatology 2014. 24:52-
59.
Gerardo J et al. Prevalence of abnormal adrenocortical function in human immunodefiency
virus by low dose cosyntropin test. Int J of STD and AIDS. 2001: 12: 804-810.
Mayo, J et al. Adrenal Function in the Human Immunodeficiency Virus-Infected Patient. Arch
Intern Med. 2002: 162: 1095-1098.
Foisy MM. et al. Adrenal suppression and Cushing’s syndrome secondary to an interaction
between ritonavir and fluticasone: a review of the literature.
54. Which of the following is the most sensitive test
for diagnosis of glucocorticoid induced diabetes?
Random plasma glucose >200 mg/dl
75 g oral glucose tolerance test (2 hour value)> 150
Fasting plasma glucose>126
Hemoglobin A1C>6.5%
55. Which of the following is the most sensitive test
for diagnosis of glucocorticoid induced diabetes?
Random plasma glucose >200 mg/dl
75 g oral glucose tolerance test (2 hour value)> 150
Fasting plasma glucose>126
Hemoglobin A1C>6.5%
56. When combined with corticosteroids, which medications has
been reported to be a contributing factor in iatrogenic
Cushing’s Syndrome?
Etravirine
Ritonavir
Zidovudine
Tenofovir
Emtricitabine
57. When combined with corticosteroids, which medications has
been reported to be a contributing factor in iatrogenic
Cushing’s Syndrome?
Etravirine
Ritonavir
Zidovudine
Tenofovir
Emtricitabine
58. Which of the following is an appropriate
screening test for Cushing’s Syndrome?
Urine Cortisol
Urine Metanephrines
Salivary Metanephrines
Cosyntropin (ACTH) stimulation test
Serum Metanephrines
59. Which of the following is an appropriate
screening test for Cushing’s Syndrome?
Urine Cortisol
Confirmatory with Dexamethasone suppression test
Urine Metanephrines
Salivary Metanephrines
Cosyntropin (ACTH) stimulation test
Serum Metanephrines
60. Although idiopathic adrenal insufficiency in HIV is rare, what
percentage of post-mortem evaluations of the adrenal gland
are abnormal?
<5%
10%
25%
33%
66%
61. Although idiopathic adrenal insufficiency in HIV is rare, what
percentage of post-mortem evaluations of the adrenal gland
are abnormal?
<5%
10%
25%
33%
66%-common sources include CMV,
Mycobacteria tuberculosis, Histoplasmosis,
PCP, Toxoplasmosis and Kaposi’s Sarcoma