AVWS in heart valve disease

Q: Which of the following cardiac valve conditions tends to cause Acquired von Willebrand syndrome (AVWS) - select one

A) Aortic stenosis (AS)

B) Mitral Stenosis (MS)

Answer: A

AS patients tend to develop AVWS and may experience cutaneous or mucosal bleeding. It directly correlates with the peak aortic gradient. The loss is primarily due to large multimers. 

A large proportion of AS patients develop anemia, with hemoglobin levels below 9 g/dL. Additionally, there is a high risk of developing gastrointestinal (GI) angiodysplasia due to both AVWS and decreased GI perfusion; the combination of AS and GI angiodysplasia is called Heyde syndrome. 

All such abnormalities resolve after corrective surgery.

AVWS is also reported in severe mitral regurgitation (MR).

#hematology

#cardiology

#surgical-critical-care

References:

1. Tamura T, Horiuchi H, Imai M, et al. Unexpectedly High Prevalence of Acquired von Willebrand Syndrome in Patients with Severe Aortic Stenosis as Evaluated with a Novel Large Multimer Index. J Atheroscler Thromb 2015; 22:1115.

2. Kapila A, Chhabra L, Khanna A. Valvular aortic stenosis causing angiodysplasia and acquired von Willebrand's disease: Heyde's syndrome. BMJ Case Rep 2014; 2014.

3. Blackshear JL, Wysokinska EM, Safford RE, et al. Shear stress-associated acquired von Willebrand syndrome in patients with mitral regurgitation. J Thromb Haemost 2014; 12:1966.

PPCM and heart transplant

Q: Patients with Peripartum Cardiomyopathy (PPCM) who undergo heart transplant have better outcomes than the comparison group.

A) True

B) False

Answer: B

Unfortunately, patients who have been transplanted for PPCM have worse outcomes compared with other cardiac transplant recipients, with higher one-year, 5-year, and 10-year mortality, higher rejection, poorer graft survival, and higher re-transplantation rates. The underlying factors are higher allo-sensitization and higher pre-transplant acuity. 

#transplantation

#cardiology

#Ob-gyn

Reference:

1. Kwon JH, Tedford RJ, Ramu B, et al. Heart Transplantation for Peripartum Cardiomyopathy: Outcomes Over 3 Decades. Ann Thorac Surg 2022; 114:650.

Soft tissue infections after trauma in water

Q: A 44-year-old male is admitted to trauma-ICU after injury while fishing at a nearby lake on his way home. Which water has a higher chance of having a soft tissue infection? - select one

A) Fresh water

B) Sea water

Answer: A

Soft-tissue infection is common after water-related injury. In terms of the highest to lowest risk for infection, it is:

• Fresh water, like ponds or small lakes
• Flowing fresh water like rivers or large lakes
• Brackish water*
• Sea water
• Treated water like swimming pools

#trauma

#ID

References:

1. Diaz JH, Lopez FA. Skin, soft tissue and systemic bacterial infections following aquatic injuries and exposures. Am J Med Sci 2015; 349:269.

2. Diaz JH. Skin and soft tissue infections following marine injuries and exposures in travelers. J Travel Med 2014; 21:207.

3. Bourque DL, Vinetz JM. Illnesses Associated with Freshwater Recreation During International Travel. Curr Infect Dis Rep 2018; 20:19.

*Brackish water is defined as water saltier than fresh water but less salty than sea water, and found where bodies of sea water and fresh water meet

Suicidal ideation, Suicide threat and Suicide gestur

Q: Suicidal ideation, Suicide threat, and Suicide gesture are different synonyms of the same concept.

A) True

B) False

Answer: B

Self-injurious thoughts may be honest, an innocent (or nocent) form of manipulation, or a form of verbalization. 

Suicidal ideation is thoughts about killing oneself; these thoughts may include a plan.

Suicide attempt is a self-injurious behavior that is intended to kill oneself, but is nonfatal.

Suicide threat is thoughts of engaging in self-injurious behavior that are verbalized and intended to lead others to think that one wants to die, despite no intention of dying.

Suicide gesture is self-injurious behavior that is intended to lead others to think that one wants to die, despite no intention of dying.

#psychiatry

References:

1. Nock MK, Favazza A. Nonsuicidal self-injury: Definition and classification. In: Understanding Non-Suicidal Self-Injury: Origins, Assessment, and Treatment, Nock MK (Ed), American Psychological Association, Washington, DC 2009.

2. Brown RC, Plener PL. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep 2017; 19:20.

3. Nock MK, Boccagno CE, Kleiman EM et al. Suicidal and nonsuicidal self-injury. In: Treatment of Childhood Disorders (in press), Fourth Edition, Prinstein MJ, Youngstrom EA, Mash EJ, and Barkley RA (Eds), Guilford Publications, New York.

4. McCullumsmith C. Laying the groundwork for standardized assessment of suicidal behavior. J Clin Psychiatry 2015; 76:e1333.

Postpartum Endometritis

Q: 32 years old female is admitted to the ICU from the OB-GYN ward with septic shock, where she was admitted 24 hours ago for delivery. The risk of postpartum endometritis is higher with? - select one

A) cesarean birth

B) vaginal birth

Answer: A

Cesarean birth, particularly when performed after the onset of labor, is the most dominant risk factor for postpartum endometritis. The risk is lower with a scheduled C-section. Antibiotic prophylaxis plays an essential role in the prevention. When an emergent C-section is required, there may be a tendency to forgo antibiotic prophylaxis.

Other significant risk factors are:

• Chorioamnionitis
• Prolonged labor
• Prolonged rupture of membranes
• Multiple cervical examinations
• Internal fetal or uterine monitoring
• Large meconium in amniotic fluid
• Manual removal of the placenta
• Maternal diabetes mellitus
• Severe anemia
• Preterm or post-term birth
• Obesity
• HIV infection
• Colonization with group B Streptococcus 
• Nasal carriage of Staphylococcus aureus
• Heavy vaginal colonization by E. coli

#ob-gyn

#ID

References:

1. Faro S. Postpartum endometritis. Clin Perinatol. 2005 Sep;32(3):803-14. doi: 10.1016/j.clp.2005.04.005. PMID: 16085035.

2. Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev 2014; :CD007482.

3. Martikaitytė J, Bartulevičienė A, Paliulytė V, Dasevičius D, Ramašauskaitė D. Postpartum Endometritis and Sepsis Associated with Gardnerella vaginalis and Anaerococcus tetradius: Case Report and Literature Review. Reports (MDPI). 2025 Aug 10;8(3):143. doi: 10.3390/reports8030143. PMID: 40843885; PMCID: PMC12371980.

Extubation failure in Parkinson's disease

Q: 72 years old male with a history of Parkinson's disease is extubated after his community-acquired pneumonia. The patient immediately developed stridor on extubation and required re-intubation. What makes Parkinson's disease a high risk of extubation?

Answer: Abnormal vocal cord closure

Patients with Parkinson's disease develop abnormal vocal cord closure as their disease progresses, causing dysphonia or hypophonia. This is due either to vocal cord rigidity or to excessive laxity. This gets compounded by multiple system atrophy. To make things further complicated, the hold of antiparkinsonian medications for any reason, like surgery or prolonged illness, makes this susceptibility worse.

#procedures

#neurology

References:

1. Gan EC, Lau DP, Cheah KL. Stridor in Parkinson's disease: a case of 'dry drowning'? J Laryngol Otol 2010; 124:668.

2. Vincken WG, Gauthier SG, Dollfuss RE, et al. Involvement of upper-airway muscles in extrapyramidal disorders. A cause of airflow limitation. N Engl J Med 1984; 311:438.

3. Easdown LJ, Tessler MJ, Minuk J. Upper airway involvement in Parkinson's disease resulting in postoperative respiratory failure. Can J Anaesth 1995; 42:344.

4. Liu EH, Choy J, Dhara SS. Persistent perioperative laryngospasm in a patient with Parkinson's disease. Can J Anaesth 1998; 45:495.

AVWS in ECMO

Q: What percentage of Extracorporeal Membrane Oxygenation (ECMO) patients develop Acquired von Willebrand syndrome (AVWS)? - select one

A) 10%

B) 25%

C) 50%

D) 75%

E) 100%

Answer: E

To date, the literature indicates that the incidence of AVWS is 100% among ECMO patients and that it typically develops within 24 hours of ECMO initiation. Fortunately, it resolves once the ECMO is decannulated. 

The contributory components are the coagulopathic effect of extracorporeal circulation, anticoagulation required for ECMO, thrombocytopathy, and, most importantly, the shear stress induced by continuous-flow via ECMO cannulae. Shear stress may damage VWF, and increased binding to platelets may enhance ADAMTS13-mediated proteolysis.

#hematology

#ECMO

References:

1. Frere C, Mazzeffi M, Maier CL, et al. Acquired von Willebrand syndrome during extracorporeal membrane oxygenation support: a comprehensive review of current evidence: communication from the ISTH SSC on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:2608.

2. Kalbhenn J, Schmidt R, Nakamura L, et al. Early diagnosis of acquired von Willebrand Syndrome (AVWS) is elementary for clinical practice in patients treated with ECMO therapy. J Atheroscler Thromb 2015; 22:265.

C-peptide level in factitious hypoglycemia

Q: A 22-year-old college student residing in a dorm presented to the ED for the third time in a month with hypoglycemia without a history of diabetes. There is a suspicion of factitious hypoglycemia, as the roommate showed suspicion that he may be using his insulin. C-peptide level is sent. In the event of factitious hypoglycemia, the C-peptide level is supposed to be? select one

A) < 0.2 nmol/L

B) ≥0.2 nmol/L 

Answer A

Two tests that rule out factitious hypoglycemia or accidental or surreptitious insulin administration are

• C-peptide level less than 0.2 nmol/L, and
• plasma proinsulin level less than 5 pmol/L        

C-peptide level ≥0.2 nmol/L and plasma proinsulin ≥5 pmol/L need to be ruled out for an endogenous origin of hyperinsulinism, or other etiologies such as oral hypoglycemic agent-induced hypoglycemia, insulin autoimmune hypoglycemia, and nesidioblastosis/islet cell hypertrophy.

#endocrinology

References:

1. Bonnet-Serrano F, Devin-Genteuil C, Thomeret L, Laguillier-Morizot C, Leguy MC, Vaczlavik A, Bouys L, Zientek C, Bricaire L, Bessiène L, Guignat L, Libé R, Mosnier-Pudar H, Assié G, Groussin L, Guibourdenche J, Bertherat J. C-peptide level concomitant with hypoglycemia gives better performances than insulin for the diagnosis of endogenous hyperinsulinism: a single-center study of 159 fasting trials. Eur J Endocrinol. 2023 Feb 14;188(2):lvad012. doi: 10.1093/ejendo/lvad012. PMID: 36756737.

2. Awad DH, Gokarakonda SB, Ilahi M. Factitious Hypoglycemia. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542310/

Hyperphosphatemia in TLS

Q: What's the cause of hyperphosphatemia in tumor lysis syndrome (TLS)?

Answer: The concentration of phosphorus in malignant cells is up to four times higher than in normal cells.

Rapid tumor breakdown during chemotherapy leads to hyperphosphatemia due to the above reason. The significant domino effect is hypocalcemia, causing tetany and/or seizures. 

When the product of calcium concentration and phosphate concentration, known as the calcium phosphate product, exceeds 60 mg2/dL2, there is a high risk of calcium phosphate precipitation in the renal tubules, leading to acute kidney injury (AKI). The same precipitation in cardiac muscles causes arrhythmias. Renal replacement therapy should be highly considered once the calcium phosphate product is ≥70 mg2/dL2. 

In the past, hyperuricemia was the leading cause of AKI in TLS. Since the advent of effective hypouricemic agents, calcium phosphate deposition, i.e., nephrocalcinosis, has become the leading cause of acute kidney injury in TLS.

#oncology

#nepheology

#electrolytes

References:

1. Kikuchi S, Muro M, Kamihara Y, Wada A, Murakami J, Nabe Y, Minemura T, Sato T. Massive hyperphosphatemia in clinical tumor lysis syndrome during prophylactic rasburicase use: risk factors and treatment options. Int Cancer Conf J. 2022 Oct 28;12(1):69-74. doi: 10.1007/s13691-022-00580-9. PMID: 36605847; PMCID: PMC9807691.

2. Amaechi PK, Jenssen F, Krishnasami Z, Achanti A, Fülöp T. Excessive elevation of serum phosphate during tumor lysis syndrome: Lessons from a particularly challenging case. Clin Nephrol Case Stud. 2021 Apr 16;9:39-44. doi: 10.5414/CNCS110086. PMID: 33884255; PMCID: PMC8056318.

3. Lindsay AB, Levy NJ, McAndrew ML. Tumor Lysis Syndrome. Emerg Med Clin North Am. 2025 Aug;43(3):453-461. doi: 10.1016/j.emc.2025.04.002. Epub 2025 May 12. PMID: 40610062.

Impetigos

Q: What is the correct combination of the following cutaneous findings of impetigo? - Combine answers in Set A with Set B

A) Nonbullous impetigo 

B) Bullous impetigo 

C) Ecthyma 

1) Perinasal and perioral regions

2) Truncal involvement 

3) The lower extremities 

Answer: A-1, B-2 and C-3

Systemic symptoms are usually absent in Impetigo. An astute clinician arrives at the diagnosis through examination of cutaneous lesions. One hallmark of the different types of impetigo is the area of involvement.

Nonbullous impetigo begins as vesicles with surrounding erythema. The lesions often coalesce and evolve into pustules that enlarge and rapidly break down, forming thick, adherent crusts with a characteristic golden yellow-brown or honey color. Commonly occurs at the perinasal and perioral regions. Lesions generally heal without scarring, but transient skin dyspigmentation may occur.

Bullous impetigo's vesicles enlarge to form flaccid bullae containing clear yellow fluid, which later become turbid. Ruptured bullae leave an erythematous, shiny, wet base with an overlying thin brown crust or a peripheral rim of scale, and truncal involvement is more common.

Ecthyma typically presents as circumscribed, "punched-out" ulcers with raised, violaceous or hyperpigmented margins and an overlying yellow-brown or dark-colored crust; the lower legs are the most common sites.

#dermatology

#ID

#clinical-exam

References:

1. Matz H, Orion E, Wolf R. Bacterial infections: uncommon presentations. Clin Dermatol 2005; 23:503.

2. Preda-Naumescu A, Elewski B, Mayo TT. Common Cutaneous Infections: Patient Presentation, Clinical Course, and Treatment Options. Med Clin North Am 2021; 105:783.

3. Saffari PS, Lee C, Acharya H. Extensive Non-Bullous Facial Impetigo in an Adult. Vis J Emerg Med. 2023 Jul;32:101754. doi: 10.1016/j.visj.2023.101754. Epub 2023 Jun 22. PMID: 37901479; PMCID: PMC10601362.

4. Brazel M, Desai A, Are A, Motaparthi K. Staphylococcal Scalded Skin Syndrome and Bullous Impetigo. Medicina (Kaunas). 2021 Oct 24;57(11):1157. doi: 10.3390/medicina57111157. PMID: 34833375; PMCID: PMC8623226.

5. Lau WC, Yang K, Lau CB, Pan CX, Kassamali B, Nambudiri VE. Clinicopathologic features of ecthyma gangrenosum: a single integrated health system cohort. Arch Dermatol Res. 2023 Nov;315(9):2717-2719. doi: 10.1007/s00403-023-02655-w. Epub 2023 Jul 11. PMID: 37432465.

The hyper-reactive malarial splenomegaly

Q: The hallmark of hyper-reactive malarial splenomegaly (HMS) is the high level of Peripheral parasitemia, diagnosed by peripheral blood slide.

A) True

B) False

Answer: B

Hyper-reactive malarial splenomegaly, also known as tropical splenomegaly syndrome, is a complication of chronic malaria. Due to long term chronic infection, peripheral parasitemia is usually absent. The diagnosis is based on combination of clinical, epidemiological, hematological, and immunological findings, like it is more common in eastern Indonesia and the Papuan highlands.

Immunologically, there is an overproduction of IgM due to repeated infection, with formation of immune complexes that cause prolonged stimulation of splenic reticuloendothelial cells. There may be a a decrease in T-suppressor lymphocytes that normally downregulate B-lymphocyte function and antibody production.

Clinically, it causes massive splenomegaly, left upper quadrant pain, fatigue, ascites, lower extremity edema, and dyspnea.

Treatment is chloroquine 300 mg base as 500 mg salt once weekly (or alternate regimen) till clinical and immunological signs resolved. Splenectomy is not recommended unless it is life threatening or there is a failure of medical treatment as mortality is very high.

#ID

References:

1. Moraes MF, Soares M, Arroz MJ, et al. [New concepts in hyperactive malarial splenomegaly]. Acta Med Port 2003; 16:41.

2. Leoni S, Buonfrate D, Angheben A, et al. The hyper-reactive malarial splenomegaly: a systematic review of the literature. Malar J 2015; 14:185.

3. Mothe B, Lopez-Contreras J, Torres OH, et al. A case of hyper-reactive malarial splenomegaly. The role of rapid antigen-detecting and PCR-based tests. Infection 2008; 36:167.

"Round belly sign"

Q: What is the "Round belly sign" on a CT scan in patients with suspicion of intra-abdominal compartment syndrome (IACS)?

Answer: The round-belly sign will be termed positive for IACS if abdominal distention has an increased ratio of anteroposterior-to-transverse abdominal diameter of more than 0.80, with 100% sensitivity and 94% specificity. Setting the value to 0.82 increased specificity to 99%.

#surgical-critical-care

References:

1. Pickhardt PJ, Shimony JS, Heiken JP, Buchman TG, Fisher AJ. The abdominal compartment syndrome: CT findings. AJR 1999;173:575 -579

2. Bouveresse S, Piton G, Delabrousse E. The round belly sign. Abdom Radiol (NY). 2017 Feb;42(2):663-664. doi: 10.1007/s00261-016-0895-4. PMID: 27638514.

3. Lombardi AF, Thompson CP, Zulfiqar M, Jain A, Krishnan I, Sandrasegaran K. Radiologic evaluation of abdominal compartment syndrome: an updated educational review. Abdom Radiol (NY). 2025 Aug 18. doi: 10.1007/s00261-025-05148-8. Epub ahead of print. PMID: 40824534.

liver abscess

Q: Liver abscesses are more commonly involved in which lobe of the liver? - select one

A) Right

B) Left

C) Caudate lobe

D) Quadrate lobe

Answer: A

The right lobe of the liver is larger and has a greater blood supply, making it the most commonly involved lobe in abscesses. The major distinction is required between a cyst and an abscess. Cysts appear as fluid collections without surrounding stranding or hyperemia. 

Another differential diagnosis is a tumor (solid), which becomes challenging when there is necrosis and bleeding within the tumor.

#hepatology

#ID

References:

1. Kozielewicz DM, Sikorska K, Stalke P. Liver abscesses – from diagnosis to treatment. Clin Exp Hepatol. 2021 Dec;7(4):329–36. doi: 10.5114/ceh.2021.110998. Epub 2021 Nov 26. PMCID: PMC8977881.

2. Lin AC, Yeh DY, Hsu YH, Wu CC, Chang H, Jang TN, Huang CH. Diagnosis of pyogenic liver abscess by abdominal ultrasonography in the emergency department. Emerg Med J. 2009 Apr;26(4):273-5. doi: 10.1136/emj.2007.049254. PMID: 19307388.

Pulmonary in SJS/TEN

Q: What could be the pulmonary findings in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)?

Answer: sloughing of the bronchial epithelium

SJS/TEN can involve any organ, including the eye, kidney, GI tract, or liver. About one in four patients gets pulmonary involvement. On bronchoscopy, sloughing of the bronchial epithelium can indicate direct pulmonary involvement. Additionally, common complications may include pneumonia, pulmonary edema, atelectasis, and ARDS. These patients have a high chance of respiratory failure requiring a ventilator.

#dermatology

#Allergy-immunology

#pulmonary

References:

1. Wankhade BS, Alrais ZF, Beniamein MMK, Issa LH, Eldelpshany MSA. Acute pulmonary complication of Stevens-Johnson syndrome-toxic epidermal necrolysis overlap. Anaesthesiol Intensive Ther. 2025 Apr 15;57(1):70-72. doi: 10.5114/ait/200234. PMID: 40237533; PMCID: PMC12210361.

2. Lee KCH, Ko JP, Oh CC, Sewa DW. Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Int J Dermatol. 2022 Jun;61(6):660-666. doi: 10.1111/ijd.15888. Epub 2021 Sep 8. PMID: 34494255.

3. Woo T, Saito H, Yamakawa Y, Komatsu S, Onuma S, Okudela K, Nozawa A, Aihara M, Ikezawa Z, Ishigatsubo Y. Severe obliterative bronchitis associated with Stevens-Johnson syndrome. Intern Med. 2011;50(22):2823-7. doi: 10.2169/internalmedicine.50.5582. Epub 2011 Nov 15. PMID: 22082897.

Proper measurement of BP

Q: While obtaining the blood pressure (BP) via the classical auscultatory method, the cuff should be deflated? - select one

A) 1 mmHg per second

B) 2 mmHg per second

C) 3 mmHg per second

Answer: B

It should always be appreciated that measuring BP via the classical auscultatory method is an art and requires precise external conditions and specific steps to perform. Careless, or in mild words, not following all steps correctly, may give wrong numbers and may harm the patient with an inappropriate prescription (or no prescription) of treatment. Readers are requested to refer pto the proper guidelines/checklists in this regard, but some vital components are:

• Avoid caffeine, exercise, and smoking for at least 30 minutes before measurement
• Empty bladder
• Sitting in a chair (feet on floor, back supported) for >5 minutes
• Remove all clothing covering the location of the cuff placement
• Reliable and calibrated device
• Arm resting on a desk
• The middle of the cuff on the patient's upper arm at the level of the right atrium (the midpoint of the sternum)
• Use the correct cuff size, such that the bladder encircles 80% of the arm
• Inflate the cuff 20 to 30 mmHg above the pulse obliteration pressure.
• Deflate the cuff pressure 2 mmHg per second, and listen for Korotkoff sounds.
• Use an average of ≥2 readings obtained on ≥2 occasions to estimate the individual's BP level

#cardiology

References:

1.  Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. 

2. Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension 2025; 82:e212.

rumination syndrome

Q: The rumination syndrome is described as recurrent vomiting in mentally disadvantaged children.

A) True

B) False

Answer: B

The rumination syndrome is frequently misdiagnosed as vomiting, gastroparesis, or gastroesophageal reflux disease (GERD). Instead, it is primarily a behavioral disorder. Unlike previously believed, it is not only limited to mentally-disadvantaged children, but it can also occur in normal adolescents and adults.

It requires only two conditions for 3 months for diagnosis (with symptom onset at least 6 months before diagnosis), and is known as the Rome IV criteria.

• Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing
• Regurgitation is not preceded by retching

Supportive symptoms are:

• Effortless regurgitation events are usually not preceded by nausea
• Regurgitant contains recognizable food that might have a pleasant taste
• The process tends to cease when the regurgitated material becomes acidic

The primary treatment is behavioral modification via diaphragmatic breathing techniques.

#GI

#psychiatry

References:

1. Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal Disorders. Gastroenterology 2016; 150:1380.

2. Pomenti S, Katzka DA. Current state of rumination syndrome. Dis Esophagus. 2024 Aug 29;37(9):doae041. doi: 10.1093/dote/doae041. PMID: 38741462.

Bulimia Nervosa - and - cardiac & skeletal muscles toxicity

Case: 22 year old female is admitted to the ICU with supraventricular tachycardia (SVT), premature atrial complexes (PACs), and hypotension. EKG also showed inverted T waves and prolonged QT and PR intervals. FoCUS at the bedside showed pericardial effusion. On exam, the patient appears to have weak skeletal muscle tone, strength, and weak reflexes. Lab showed elevated Liver enzymes. The patient has been previously admitted to the hospital with electrolyte imbalances and has been diagnosed with bulimia nervosa. Patient acknowledged that recently she started using Ipecac.

Answer: About one in five patients with bulimia nervosa may ingest ipecac to induce vomiting. Ipecac contains emetine, which, along with electrolyte imbalances, causes severe cardiac and skeletal muscle myopathy. Emetine is eliminated from patients very slowly. It can be found in urine even after two months of use. Small, chronic doses may have cumulative and fatal toxicity. Moreover, the absorption of emetine is enhanced in patients who become refractory to the emetic effects of the drug with chronic misuse. The worst part is that emetine accumulates in cardiac muscle cells, is toxic and emetine induced cardiomyopathy may be irreversible. Although cases have been reported of reversibility but cardiac dysfunction from associated electrolyte abnormalities is hard to distinguish. The only treatment is supportive care. There is no antidote.

Fortunately, skeletal muscle weaknesses can be reversed, though slowly, with physical therapy as emetine gets eliminated from the body.

#toxicology

References:

1. Effects of ipecac on the heart. N Engl J Med. 1986 May 8;314(19):1253-5. doi: 10.1056/NEJM198605083141914. PMID: 2871487.

2. Steffen KJ, Mitchell JE, Roerig JL, Lancaster KL. The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives. Int J Eat Disord 2007; 40:360.

3. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016; 129:30.

4. Dresser LP, Massey EW, Johnson EE, Bossen E. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatry. 1993 May;56(5):560-2. doi: 10.1136/jnnp.56.5.560. PMID: 8099367; PMCID: PMC1015020.

ETOH treatment

Q: 58 years old male is admitted to the ICU with severe alcohol ketoacidosis (AKA). Patient is now recovering in the ICU. The patient has previously failed many interventions to quit alcohol, and now desires only to reduce his dependence on ETOH, and feels he can't stop it completely. The pharmacologic treatment of ETOH disorder can be carved with the treatment goal to?

A) Complete abstinence 

B) Reduction of use

C) Either

Answer: C

It may be interesting that many patients with Alcohol/ETOH abuse may desire to reduce their dependence only!

Disulfiram is a known pharmacologic treatment when complete abstinence is desired.

In cases where the patient's treatment goal is only the reduction of use, naltrexone, acamprosate, and topiramate can be utilized.

Said all of the above, a trained clinician should take the initiative in treating such a disorder, as these patients frequently have many co-occurring morbidities, a preference for different modalities such as monthly injection versus daily medication, a rate of noncompliance, and a previous history of relapses.

#toxicology

References:

1. Mann K, Aubin HJ, Witkiewitz K. Reduced Drinking in Alcohol Dependence Treatment, What Is the Evidence? Eur Addict Res. 2017;23(5):219-230. doi: 10.1159/000481348. Epub 2017 Sep 22. PMID: 28934736.

2. Henssler J, Müller M, Carreira H, Bschor T, Heinz A, Baethge C. Controlled drinking-non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta-analysis and meta-regression. Addiction. 2021 Aug;116(8):1973-1987. doi: 10.1111/add.15329. Epub 2020 Dec 14. PMID: 33188563.

3. Fukuda T, Nakai M, Murakami M. [Reduction in alcohol consumption as a treatment goal of alcohol dependence: actual conditions in Okinawa]. Nihon Arukoru Yakubutsu Igakkai Zasshi. 2013 Feb;48(1):58-63. Japanese. PMID: 23659006.

HCAP

Q: Health care-associated pneumonia (HCAP) is a critical concept for any clinician to be aware of, as it helps start antibiotics before cultures are available, saves lives, and decreases overall use of inappropriate antibiotics.

A) True

B) False

Answer: B

The category/idea/concept of health care-associated pneumonia (HCAP) has been removed from the 2016 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, as well as the combined 2017 European and Latin American Hospital-acquired pneumonia (HAP) (nosocomial) guidelines.

Previously, HCAP was defined as pneumonia acquired in health care facilities such as Long-Term Acute Care (LTAC), nursing homes, rehab centers, hemodialysis centers, or outpatient clinics, or within 90 days of a hospitalization. The whole purpose was to treat with antibiotics at the early stage of infection, particularly multidrug-resistant (MDR) infections. 

Later studies and evidence have shown that this was not a very prudent approach, as it led to increased, more inappropriate use of broad-spectrum antibiotics. The use of 'big guns' antibiotics was very high in comparison to the risk for MDR pathogens. This negates the concept of 'antibiotics stewardship'.

A new approach returns to the previous practice of treating HCAP as community-acquired pneumonia (CAP), and decides whether to consider MDR pathogens on a case-by-case basis based on prior exposures, risk factors, severity of illness, prior antimicrobial use, comorbidities, and functional status.

#ID

References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

3. Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50.

4. Kollef MH. Health care-associated pneumonia: perception versus reality. Clin Infect Dis 2009; 49:1875.

5. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330.

substernal goiter

Q; 52 years old female from Denmark* presented to ED with sudden enlargement of her known substernal goiter associated with pain. A bedside ultrasound followed by a CT scan confirmed hemorrhage into a goiter. Substernal goiter enlargement tends to do more of what? - select one

A) dysphagia 

B) stridor

Answer: B

Dysphagia is less common in substernal goiter because the esophagus is posteriorly located. An obstructive cervical or substernal goiter can enlarge and press on the trachea; when the tracheal lumen is less than 5 mm, stridor or wheezing at rest is expected. It would be prudent to secure the airway before relieving compression in acute cases. An experienced anesthesiologist should be called, as the margin of error is small.

Other symptoms which may occur are compression of a recurrent laryngeal nerve causing transient or permanent vocal cord palsy, manifesting as hoarseness, phrenic nerve paralysis, Horner's syndrome due to compression of the cervical sympathetic chain, and, in a few cases, jugular vein compression or thrombosis, cerebrovascular steal syndromes, or the superior vena cava syndrome.

#ENT

#endocrinology

#procedures

#surgical-critical-care

References:

1. O’Connor, Eoin, Looney, Michael, Lennon, Emma - Massive retrosternal goitre causing stridor and respiratory distress—a case report - Journal of Emergency and Critical Care Medicine - Vol 9 (March 30, 2025) /, https://jeccm.amegroups.org/article/view/8867

2. Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis 1975; 111:631.

3. Aragón Valera C, Antón Bravo T, Sanchón Rodríguez R, Martínez Bermejo E, Paniagua Ruiz A, Alvarez Santirso R. Dyspnea and stridor due to multinodular goiter in an obese woman. Endocrinol Nutr. 2008 May;55(5):234-6. English, Spanish. doi: 10.1016/S1575-0922(08)70674-0. Epub 2008 Oct 15. PMID: 22967919.

*Denmark epidemiology is consistent with mild-to-moderate iodine-deficient goiter.

IG and HG

Q: What's the difference between immune globulin (IG) and hyperimmune globulin (HG)?

Answer:

Immune globulin is derived from the plasma of random donors. It can be used for an array of disorders, including primary and secondary immune deficiency states, as well as many autoimmune and inflammatory disorders. It is mainly given intravenously (IVIG), but can also be given subcutaneously (SCIG) or intramuscularly (IMIG). Additives and stabilizers are usually added to the product.

Hyperimmune globulin refers to immune globulin obtained from the plasma of individuals with high titers of specific antibodies to certain pathogens, or from individuals immunized or naturally exposed to particular antigens. In some diseases, it can also be obtained from animals.

#immunology

References:

1. Schroeder HW Jr, Cavacini L. Structure and function of immunoglobulins. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S41-52. doi: 10.1016/j.jaci.2009.09.046. PMID: 20176268; PMCID: PMC3670108.

2. Novaretti MC, Dinardo CL. Immunoglobulin: production, mechanisms of action and formulations. Rev Bras Hematol Hemoter. 2011;33(5):377-82. doi: 10.5581/1516-8484.20110102. PMID: 23049343; PMCID: PMC3415776.

3. Pati I, Cruciani M, Candura F, Massari MS, Piccinini V, Masiello F, Profili S, De Fulvio L, Pupella S, De Angelis V. Hyperimmune Globulins for the Management of Infectious Diseases. Viruses. 2023 Jul 13;15(7):1543. doi: 10.3390/v15071543. PMID: 37515229; PMCID: PMC10385259.

allopurinol and heart

Q: Allopurinol can be used as an anti-anginal drug.

A) True

B) False

Answer: A

There is weak evidence that Allopurinol, a xanthine oxidase inhibitor, may be beneficial in stable angina.

It significantly increased the median time to ST depression and the median total exercise time when compared to placebo.

The mechanism of action is proposed to be improved endothelium-dependent vasodilation and the abolition of oxidative stress. The suggested dose is 600 mg per day.

#cardiology

#pharmacology

References:

1. Noman A, Ang DS, Ogston S, et al. Effect of high-dose allopurinol on exercise in patients with chronic stable angina: a randomised, placebo controlled crossover trial. Lancet 2010; 375:2161.

2. Rajendra NS, Ireland S, George J, et al. Mechanistic insights into the therapeutic use of high-dose allopurinol in angina pectoris. J Am Coll Cardiol 2011; 58:820.

Urine Dipstick in the Rapid Diagnosis of Septic Arthritis

Q: What is the urine "dipstick" test, which can help in the diagnosis of septic arthritis?

Answer:

The two confirmatory (aka gold standard) tests for diagnosing a septic joint are synovial fluid culture or synovial biopsy. Said that many times: both are hard to obtain or require a wait for results.

Many adjuvant tests help to establish a probable diagnosis, along with clinical signs and other tests such as blood counts and blood cultures. Recently, nucleic acid amplification tests like polymerase chain reaction (PCR) and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectometry have been used at advanced centers, particularly when routine cultures are negative but clinical suspicion is high. But these tests are time-consuming and not very cost-effective.

Interestingly, a simple, quick, and highly cost-effective urine "dipstick" test to measure synovial fluid leukocyte esterase can be used as an adjunct to diagnose septic arthritis (reference 1 for details).

#ID

#laboratory-medicine

#rheumatology

References:

1. Aslani H, Pasha Zanoosi MR, Navali AM. Urine Dipstick Leukocyte Esterase in the Rapid Diagnosis of Septic Arthritis. Arch Bone Jt Surg. 2022 Jan;10(1):38-44. doi: 10.22038/ABJS.2021.47573.2334. PMID: 35291247; PMCID: PMC8889425.

2. Dey M, Al-Attar M, Peruffo L, et al. Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1740.

2. Sanpera I, Salom M, Alves C, Eastwood D. Diagnosis and management of septic arthritis: A current concepts review. J Child Orthop. 2025 Jan 2;19(1):14-19. doi: 10.1177/18632521241311302. PMID: 39758603; PMCID: PMC11694264.