Steroids, underlying infection and HES

Q: 34 years old male who recently migrated from Brazil is admitted to the ICU with a mental status change. Initial workup showed hypereosinophilic syndrome (HES) with absolute eosinophil count (AEC) above 100 x 109/L. High-dose glucocorticoids is decided as an immediate management. Which one of the underlying diseases needs to be ruled out?

Answer: strongyloidiasis

Strongyloidiasis needs to be ruled out in patients from highly endemic areas. Glucocorticoids may precipitate potentially fatal dissemination, causing hyperinfection syndrome. Ideally, these patients should be treated with ivermectin (200 mcg/kg daily) for two days prior.

In patients who need urgent treatment, like the patient in the above question with organ involvement, ivermectin may be given concomitantly with glucocorticoids. In fact, all at-risk patients should be treated, even if the serology is negative, as serology is not a reliable test, and stool examination for larvae is also insensitive.

Glucocorticoids accelerate the apoptosis and/or sequestration of eosinophils.

#ID

#hematology

References:

1. Shomali W, Gotlib J. World Health Organization and International Consensus Classification of eosinophilic disorders: 2024 update on diagnosis, risk stratification, and management. Am J Hematol. 2024 May;99(5):946-968. doi: 10.1002/ajh.27287. Epub 2024 Mar 29. PMID: 38551368.

2. Simon HU, Klion A. Therapeutic approaches to patients with hypereosinophilic syndromes. Semin Hematol. 2012 Apr;49(2):160-70. doi: 10.1053/j.seminhematol.2012.01.002. PMID: 22449626; PMCID: PMC3314228.

3. Khadka P, Khadka P, Thapaliya J, Karkee DB. Fatal strongyloidiasis after corticosteroid therapy for presumed chronic obstructive pulmonary disease. JMM Case Rep. 2018 Sep 11;5(9):e005165. doi: 10.1099/jmmcr.0.005165. PMID: 30425838; PMCID: PMC6230759.

4. Domínguez VR, Pérez-López C, Sánchez CV, Contreras CU, Guerrero AI, Abenza Abildúa MJ. Strongyloides hyperinfection syndrome due to corticosteroid therapy after resection of meningioma: illustrative case. J Neurosurg Case Lessons. 2022 Jul 11;4(2):CASE21667. doi: 10.3171/CASE21667. PMID: 35855010; PMCID: PMC9274291.

Symptoms in bilateral vocal cord paralysis

Q: 64 years old male post-double lung transplant is found to have bilateral vocal cord paralysis after extubation. In exclusive bilateral vocal cord paralysis, which of the following is most likely?

A) Compromised voice quality

B) Respiratory symptoms

Answer: B

The voice quality is usually not compromised in local exclusive bilateral vocal fold paralysis. On exam, bilaterally denervated vocal folds appear midline, with a narrow glottic aperture. Voice is generally good with this glottic configuration. The primary symptoms are respiratory, including minimal dyspnea, inspiratory stridor, or severe respiratory distress. Phrenic nerve injury is a frequent side effect post-double lung transplant, though any clinical suspicion needs to be ruled out. The dysphonia due to respiratory symptoms is called 'breathy dysphonia'. Local edema and irritation caused by intubation may result in some hoarseness, which typically resolves.

This question again emphasizes the importance of close clinical observations and the skills of history taking and physical examination.

Post-tracheal intubation is the leading cause of bilateral vocal fold paralysis in intensive care units (ICUs). 

Other causes are:

• Neck surgery, like Recurrent laryngeal nerve palsy post carotid endarterectomy (CEA)}
• ALS
• Diabetic neuropathy
• Myasthenia gravis
• Organophosphate poisoning
• Administration of vinca alkaloids
• Stroke
• Head injury
• hydrocephalus 
• Brainstem compression 
• Arnold-Chiari malformation 
• Bilateral cricoarytenoid joint fixation (rheumatoid arthritis)

#procedures

#ENT

References:

1. Jean M Bruch, Dipti V Kamani, Daniel G Deschler, Zehra Hussain : Hoarseness in adults :: Source: https://www.uptodate.com/contents/hoarseness-in-adults (accessed on April 26, 2025)

2. Hillel AD, Benninger M, Blitzer A, Crumley R, Flint P, Kashima HK, Sanders I, Schaefer S. Evaluation and management of bilateral vocal cord immobility. Otolaryngol Head Neck Surg. 1999 Dec;121(6):760-5. doi: 10.1053/hn.1999.v121.a98733. PMID: 10580234.

AF and AI

Q: Computer (AI) based interpretation for Atrial Fibrillation (AF) of EKG is usually accurate?

A) True

B) False

Answer: B

To date, the data does not support the reliability of automated computer or Artificial intelligence-based readings of AF. Ten to thirty percent of computer ECG interpretations may misdiagnose AF. This is also because the algorithms used by various computers and AI are not standardized, validated, or well-clarified.

Said that some of the newer studies claimed (reference # 3 and 4) that a new deep densely connected neural network (DDNN) based on different principles than the usual method via machine learning, and Supervised Contractive Map (SVCm), reached an overall mean accuracy of 95%. This claim needs to be validated and endorsed by relevant societies. The best we can say is that "the Jury is still out".

To date, each ECG computer should be read by a trained clinician, although computer reading may be of assistance.

#cardiology

#AI

References:

1. Bogun F, Anh D, Kalahasty G, et al. Misdiagnosis of atrial fibrillation and its clinical consequences. Am J Med 2004; 117:636.

2. Lindow T, Kron J, Thulesius H, et al. Erroneous computer-based interpretations of atrial fibrillation and atrial flutter in a Swedish primary health care setting. Scand J Prim Health Care 2019; 37:426.

3. Buscema PM, Grossi E, Massini G, Breda M, Della Torre F. Computer Aided Diagnosis for atrial fibrillation based on new artificial adaptive systems. Comput Methods Programs Biomed. 2020 Jul;191:105401. doi: 10.1016/j.cmpb.2020.105401. Epub 2020 Feb 19. PMID: 32146212.

4. Cai W, Chen Y, Guo J, Han B, Shi Y, Ji L, Wang J, Zhang G, Luo J. Accurate detection of atrial fibrillation from 12-lead ECG using deep neural network. Comput Biol Med. 2020 Jan;116:103378. doi: 10.1016/j.compbiomed.2019.103378. Epub 2019 Aug 2. PMID: 31778896.

10:6 rule in Dig toxicity

Q: What is the rule of 10:6 in digoxin toxicity?

Answer:

The 'rule of 10:6 is easy to remember and may be helpful while ordering Digoxin immune Fab (digibind, DigiFab) in patients with digoxin toxicity.

• If an unknown amount is acutely ingested, 10 vials can be administered; an additional 10 vials can be given if necessary.
• In chronic digoxin therapy, where toxicity is suspected, 6 vials are usually sufficient to resolve symptoms.

If required, the digibind dose can be calculated by using the formula:

number of vials = (digoxin concentration) x (patient's weight) / 100

EKG changes are the best way to monitor resolution. Resolution may be visible within 30 minutes, but it takes 2-4 hours to take full effect. 

Each vial of DigiFab contains 40 mg of Fab, which binds 0.5 mg of digoxin. DigiFab is usually given in an IV preparation over 30 minutes, but an IV push can be given in life-threatening situations. It may cause some febrile reactions. It should be avoided in patients with an allergy to sheep protein and papaya extracts.

#toxicity

# pharmacology

Recommended readings:

1. Wei S, Niu MT, Dores GM. Adverse Events Associated with Use of Digoxin Immune Fab Reported to the US Food and Drug Administration Adverse Event Reporting System, 1986-2019. Drugs Real World Outcomes. 2021 Jun;8(2):253-262. doi: 10.1007/s40801-021-00242-x. Epub 2021 Mar 15. PMID: 33721285; PMCID: PMC8128941.

2. Ip D, Syed H, Cohen M. Digoxin specific antibody fragments (Digibind) in digoxin toxicity. BMJ. 2009 Sep 3;339:b2884. doi: 10.1136/bmj.b2884. PMID: 19729422.

3. Lucyk S. Calculated decisions: DigiFab® (Digibind®) Dosing for Digoxin Poisoning. Emerg Med Pract. 2020 Sep 15;22(Suppl 9):CD1-CD3. PMID: 33476509.

Campylobacter jejuni infection and Guillain-Barré syndrome

Q: 54 years old male with no past medical history is admitted to ICU with shortness of breath, requiring intubation. Further workup led to the diagnosis of Guillain-Barré Syndrome (GBS). Wife reported patient having severe viral diarrheal illness four weeks ago. Patients who develop Campylobacter jejuni infection-related Guillain-Barré syndrome (GBS) tend to recover quickly and have better outcomes.

A) True 

B) False

Answer: B

A quarter of patients who develop GBS are found to have C. jejuni gastroenteritis within 12 weeks of its onset. Overall, two-thirds of patients have some kind of antecedent respiratory tract or gastrointestinal infection. The risk of developing GBS within eight weeks of a symptomatic C. jejuni infection is about 100-fold higher!

Unfortunately, Campylobacter-associated GBS tends to have a worse prognosis, followed by a slower recovery and higher residual neurologic disability.

#ID

#neurology

References:

1. Rees JH, Soudain SE, Gregson NA, Hughes RA. Campylobacter jejuni infection and Guillain-Barré syndrome. N Engl J Med 1995; 333:1374.

2. Leonhard SE, van der Eijk AA, Andersen H, et al. An International Perspective on Preceding Infections in Guillain-Barré Syndrome: The IGOS-1000 Cohort. Neurology 2022; 99:e1299.

3. McCarthy N, Giesecke J. Incidence of Guillain-Barré syndrome following infection with Campylobacter jejuni. Am J Epidemiol 2001; 153:610.

4. Griffin JW, Li CY, Ho TW, et al. Pathology of the motor-sensory axonal Guillain-Barré syndrome. Ann Neurol 1996; 39:17.

Gabapentin and ETOH disorder

Q: 57 years old male with history of active alcoholism is admitted to the ICU after Motor Vehicle Accident (MVA), requiring orthopedic surgery. The on-call resident wanted to initiate the Enhanced Recovery After Surgery (ERAS) protocol, which includes the use of Gabapentin. It is not a good idea to prescribe Gabapentin to a patient with a history of alcohol abuse.

A) True

B) False

Answer: B

Gabapentin is considered one of the second-line drugs for patients with alcohol abuse. It has been shown to decrease the heavy drinking days. The beneficial effect of Gabapentin gets even more pronounced in withdrawal symptoms, like patient in this question who is at high risk of Delirium Tremens (DT) while recovering in the ICU.

Another such drug described with beneficial effects is Baclofen.

#toxicity

#ETOH-abuse

#pharmacology

References:

1. Mason BJ, Quello S, Goodell V, et al. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med 2014; 174:70.

2. Anton RF, Latham P, Voronin K, et al. Efficacy of Gabapentin for the Treatment of Alcohol Use Disorder in Patients With Alcohol Withdrawal Symptoms: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:728.

3. Gratacós-Ginès J, Bruguera P, Pérez-Guasch M, et al. Medications for alcohol use disorder promote abstinence in alcohol-associated cirrhosis: Results from a systematic review and meta-analysis. Hepatology 2024; 79:368.

4. Rose AK, Jones A. Baclofen: its effectiveness in reducing harmful drinking, craving, and negative mood. A meta-analysis. Addiction 2018; 113:1396.

AUDIT-C

Q: 75 years old male is admitted to ICU after Coronary artery bypass surgery. Patient has significant agitation while coming out of sedation for extubation. Review of chart shows an AUDIT-C score of 10. AUDIT-C has clinical significance for which underlying disorder? - Select one

A) Alcohol abuse

B) Barbiturate dependence

C) Cocaine abuse

D) Dementia risk factor

E) Epilepsy risk factor

Answer: A

Frequently missed or not performed preoperatively in surgical patients undergoing high-risk cases is a simple three-question alcohol abuse score. The following three questions are asked, each graded on a scale of 0 to 4 points.

1. How often did you have a drink containing alcohol in the past year?
2. How many drinks did you have on a typical day when you were drinking in the past year?
3. How often did you have 6 or more drinks on one occasion in the past year?

A score of 4 or more is considered positive in men, and a score of 3 or more is considered positive in women.

AUDIT-C calculator is readily available from any search engine.

#surgical-critical-care

#ETOH-abuse

References:

1. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998 Sep 14;158(16):1789-95. doi: 10.1001/archinte.158.16.1789. PMID: 9738608.

2. Simon CB, McCabe CJ, Matson TE, Oliver M, Bradley KA, Hallgren KA. High test-retest reliability of the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire completed by primary care patients in routine care. Alcohol Clin Exp Res (Hoboken). 2024 Feb;48(2):302-308. doi: 10.1111/acer.15245. Epub 2023 Dec 23. PMID: 38099421; PMCID: PMC10922542.

high-trauma versus low-trauma fracture

Q: What are high and low trauma fractures?

Answer: High-trauma and low-trauma fractures are conventionally differentiated based on the force to which the bone is subjected, or by assuming that the level of force is high enough to break any normal bone.

• High-trauma fractures usually occur from motor vehicle accidents (MVA), sports, or falls.
• Low-trauma fractures, also known as fragility fractures, occur due to minimal trauma in weakened bones. 

Clinical implication: This classical differentiation has been questioned by many critics as patients with low Bone Mineral Density (BMD) also increase the risk of high-trauma fractures. Most high-trauma fractures are usually excluded from observational and osteoporosis trials, which may bias the studies due to erroneous selection criteria.

#trauma

#orthopedics

References:

1. Khosla S. High-trauma fractures and bone mineral density. JAMA 2007; 298:2418.

2. Sanders KM, Pasco JA, Ugoni AM, et al. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. J Bone Miner Res 1998; 13:1337.

3. Leslie WD, Schousboe JT, Morin SN, Martineau P, Lix LM, Johansson H, McCloskey EV, Harvey NC, Kanis JA. Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study. Osteoporos Int. 2020 Jun;31(6):1059-1067. doi: 10.1007/s00198-019-05274-2. Epub 2020 Mar 16. PMID: 32173782; PMCID: PMC7115893.

DGI

Q: 35 years old female with no past medical history is admitted to ICU with sepsis-like symptoms. On examination, the patient is found to have asymmetric pain and swelling on the knees, wrists, and ankle joints. Patient acknowledged having more than one sexual partner in the last few months and having unprotected sex. The patient was diagnosed with disseminated gonococcal infection (DGI) with septic arthritis. These subsets of patients tend to present with high fevers.

A) True

B) False

Answer: B

Patients with DGI present in two distinct categories for reasons not yet fully understood.

1. Arthritis-dermatitis syndrome, which has a classic triad of

• tenosynovitis
• dermatitis, and 
• polyarthralgia

2. Purulent arthritis

Later, as the disease advances, two forms may intermingle and further disseminate with endocarditis, myopericarditis, meningitis, osteomyelitis, abscesses, and vasculitis.

Fever, chills, and generalized malaise are common in arthritis-dermatitis syndrome. Also, it is interesting that as the disease advances, this fever tends to disappear relatively abruptly, leaving the notion that the patient might have flu-like symptoms. This delays seeking care significantly.

#ID

#rheumatology

#ob-gyn

References:

1. Bleich AT, Sheffield JS, Wendel GD Jr, et al. Disseminated gonococcal infection in women. Obstet Gynecol 2012; 119:597.

2. Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol 2003; 17:201.

3. Gelfand SG, Masi AT, Garcia-Kutzbach A. Spectrum of gonococcal arthritis: evidence for sequential stages and clinical subgroups. J Rheumatol 1975; 2:83.

4. García-De La Torre I, Nava-Zavala A. Gonococcal and nongonococcal arthritis. Rheum Dis Clin North Am 2009; 35:63.

Orthostatic hypotension

Q: Orthostatic hypotension is defined as a drop in systolic blood pressure of at least _____________ mmHg on standing. - Select one

A) 10 mmHg

B) 20 mmHg

Answer: B

Orthostatic hypotension (OH) is quantitatively defined as a drop of at least

• 20 mmHg of systolic blood pressure, or
• 10 mmHg of diastolic blood pressure

Within the first three minutes of standing. 

The same definition applies to head-up tilt on a tilt table test. Postprandial hypotension (PH) and neurogenic OH (nOH) are variants of orthostatic hypotension.

#hemodynamic

References:

1. Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol. 2022 Aug;21(8):735-746. doi: 10.1016/S1474-4422(22)00169-7. PMID: 35841911; PMCID: PMC10024337.

2. Ringer M, Hashmi MF, Lappin SL. Orthostatic Hypotension. 2025 Jan 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28846238.

3. Bradley JG, Davis KA. Orthostatic hypotension. Am Fam Physician. 2003 Dec 15;68(12):2393-8. PMID: 14705758.

infection and psoriatic Arthritis

Q: Which infection is associated with psoriatic Arthritis (PsA)? - select one

A) Staphylococcal

B) Streptococcal 

Answer: B

Although not confirmed, there is some weak evidence that points to PsA may be preceded by streptococcal infection. One classic example is the occurrence of guttate psoriasis after streptococcal infection. Also, improvement in PsA skin lesions after tonsillectomy has been reported. Skin biopsy and analysis of psoriatic and psoriatic plaques showed increased bacterial diversity, including more Streptococcus, compared to the control group.

#derm

#ID

References:

1. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al. Improvement of psoriasis after tonsillectomy is associated with a decrease in the frequency of circulating T cells that recognize streptococcal determinants and homologous skin determinants. J Immunol 2012; 188:5160.

2. Rasmussen JE. The relationship between infection with group A beta hemolytic streptococci and the development of psoriasis. Pediatr Infect Dis J 2000; 19:153.

3. Vasey FB, Deitz C, Fenske NA, et al. Possible involvement of group A streptococci in the pathogenesis of psoriatic arthritis. J Rheumatol 1982; 9:719.

CEUS

Q: Contrast-enhanced ultrasonography of the Kidney should be avoided in patients with renal insufficiency to avoid Contrast-Induced Nephropathy (CIN).

A) True

B) False

Answer: B

Contrast-enhanced ultrasonography (CEUS) of the kidney doesn't involve Intravenous (IV) dye contrast. Instead, it consists of an IV injection of microbubbles. 

CEUS is very useful in distinguishing vascular from avascular masses. Its specificity is as good as CT or MRI. Another use is in the diagnosis of vesicoureteral reflux.

#procedures

#radiology

References:

1. Atri M, Jang HJ, Kim TK, Khalili K. Contrast-enhanced US of the Liver and Kidney: A Problem-solving Modality. Radiology 2022; 303:11.

2. Ntoulia A, Back SJ, Shellikeri S, et al. Contrast-enhanced voiding urosonography (ceVUS) with the intravesical administration of the ultrasound contrast agent Optison™ for vesicoureteral reflux detection in children: a prospective clinical trial. Pediatr Radiol 2018; 48:216.

3. Tufano A, Drudi FM, Angelini F, Polito E, Martino M, Granata A, Di Pierro GB, Kutrolli E, Sampalmieri M, Canale V, Flammia RS, Fresilli D, Bertolotto M, Leonardo C, Franco G, Cantisani V. Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Renal Masses with Histopathological Validation-Results from a Prospective Single-Center Study. Diagnostics (Basel). 2022 May 12;12(5):1209. doi: 10.3390/diagnostics12051209. PMID: 35626364; PMCID: PMC9140371.

CCB overdose and pressor

Q: Which of the following is the choice of pressor in Calcium Channel Blocker (CCB) induced hypotension? - Pick one

A) Norepinephrine

B) Vasopressin

Answer: A

In CCB overdose or exaggerated response, there is a need for a direct-acting agent with 

• positive inotropy
• positive chronotropy, and
• vasoconstrictive effects

Based on this, norepinephrine (NE) appears to be the best initial choice for a pressor.

If NE has reached its maximum infusion dose, Epinephrine and Dopamine (with similar properties) can be added. NE takes precedence over 'epi' and 'dopa' due to its relatively less arrhythmogenic effect at higher doses.

CCB toxicity requires a multi-front approach, along with pressors with

• IV boluses of isotonic crystalloid
• IV calcium infusion
• IV glucagon
• IV high-dose insulin and glucose
• IV lipid emulsion therapy (+/-)
• ECMO (as a last resort)

#toxicity

#pharmacology

#hemodynamic

References:

1. St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W 2nd, Laliberté M, Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45(3):e306-e315. doi: 10.1097/CCM.0000000000002087. PMID: 27749343; PMCID: PMC5312725.

2. Alshaya OA, Alhamed A, Althewaibi S, Fetyani L, Alshehri S, Alnashmi F, Alharbi S, Alrashed M, Alqifari SF, Alshaya AI. Calcium Channel Blocker Toxicity: A Practical Approach. J Multidiscip Healthc. 2022 Aug 30;15:1851-1862. doi: 10.2147/JMDH.S374887. PMID: 36065348; PMCID: PMC9440664.

3. Finn D, Stevens J, Tolkacz M, Robinson J, Mangla J, Iacco A. Calcium Channel Blocker Overdose: What Role Does Extracorporeal Membrane Oxygenation Have in Support? A Systematic Review of the Literature. ASAIO J. 2024 May 1;70(5):404-408. doi: 10.1097/MAT.0000000000002129. Epub 2024 Jan 2. PMID: 38165982.

EJV and IJV

Q: The size of the external jugular vein (EJV) is ________________ related to the size of the internal jugular vein (IJV)? - Select one

A) directly

B) inversely

Answer: B

There is an inverse correlation between the size of the external and internal jugular veins.

Clinical significance: If you see a large EJV on patient's neck, expect potentially more difficult internal jugular venepuncture.

#procedures

References:

1. Stickle BR, McFarlane H. Prediction of a small internal jugular vein by external jugular vein diameter. Anaesthesia. 1997 Mar;52(3):220-2. doi: 10.1111/j.1365-2044.1997.078-az0076.x. PMID: 9124661.

Phenytoin and albumin

Q: Phenytoin level needs to be corrected with serum albumin level?

A) Yes

B) No

Answer: A

Phenytoin is protein-bound, and clinical symptoms correlate well with its level. Although not very precise, hypoalbuminemia needs to be corrected using the Sheiner-Tozer formula.

Corrected total phenytoin concentration = Observed total phenytoin concentration/([0.2 x Albumin]+0.1)

A major criticism of the Sheiner-Tozer equation is that it depends on various factors, such as temperature, timing of concentration sampling, steady-state dosing conditions, renal function, age, concomitant medications, and patient type. 

Other option is to use free phenytoin level, but usually it's not widely available in all hospitals' laboratories.

#pharmacology

References:

1. Kiang TK, Ensom MH. A Comprehensive Review on the Predictive Performance of the Sheiner-Tozer and Derivative Equations for the Correction of Phenytoin Concentrations. Ann Pharmacother. 2016 Apr;50(4):311-25. doi: 10.1177/1060028016628166. Epub 2016 Jan 29. PMID: 26825643.

2. Dager WE, Inciardi JF, Howe TL. Estimating phenytoin concentrations by the Sheiner-Tozer method in adults with pronounced hypoalbuminemia. Ann Pharmacother. 1995 Jul-Aug;29(7-8):667-70. doi: 10.1177/106002809502907-802. PMID: 8520077.

3. Bolt J, Gorman SK. Precision, bias, and clinical utility of the Sheiner-Tozer equation to guide phenytoin dosing in critically ill adults. J Clin Pharmacol. 2013 Apr;53(4):451-5. doi: 10.1002/jcph.27. Epub 2013 Feb 22. PMID: 23436385.

ORD

Case: 22 years old female is admitted to ICU for suicidal watch. She attempted suicide as she was unable to get rid of her foul-smelling odor despite assurances from friends and family that she had no such issue. The patient was diagnosed with Olfactory reference disorder (ORD). 

Discussion: ORD is a disease where a patient has a persistent preoccupation with emitting a foul body odor about himself. It can be an occupation with bad breath, sweat, flatulence, urine, or the genital area.

In psychiatric literature, it has been described as olfactory delusional syndrome, olfactory paranoid syndrome, delusional halitosis, imaginary halitosis, monosymptomatic hypochondriacal psychosis, and bromidrosiphobia. 

It is not entirely clear that ORD is purely a psychiatric disorder or has underlying neurological pathophysiology. Single-photon emission computed tomography (SPECT) imaging in these patients found decreased perfusion in the left frontotemporal region with multiple additional perfusion defects.

SSRI (Selective Serotonin Reuptake Inhibitor) may be effective.

#psychiatry

References:

1. Begum M, McKenna PJ. Olfactory reference syndrome: a systematic review of the world literature. Psychol Med 2011; 41:453.

2. Stein DJ, Le Roux L, Bouwer C, Van Heerden B. Is olfactory reference syndrome an obsessive-compulsive spectrum disorder?: two cases and a discussion. J Neuropsychiatry Clin Neurosci 1998; 10:96.

3. Konuk N, Atik L, Atasoy N, Ugur MB. Frontotemporal hypoperfusion detected by 99mTc HMPAO SPECT in a patient with olfactory reference syndrome. Gen Hosp Psychiatry 2006; 28:174.

4. Skimming KA, Miller CWT. Transdiagnostic Approach to Olfactory Reference Syndrome: Neurobiological Considerations. Harv Rev Psychiatry. 2019 May/Jun;27(3):193-200. doi: 10.1097/HRP.0000000000000215. PMID: 31082994.

signet / cabochon ring sign

Q: The presence of Signet or Cabochon ring sign on CT chest is mainly associated with which lung disease?

Answer: Bronchiectasis

Bronchiectasis can be diagnosed on CT chest by some of the hallmark signs such as:

1. their continuity with an airway

2. tendency to form clusters

3. formation of tramlines or honeycombing

4. signet  or Cabochon ring sign

Tramlines' appearance is due to dilated, thickened bronchial walls, and a signet or cabochon ring sign appears when the bronchus becomes larger than the corresponding vessel. In normal lungs, the vessel is larger than the corresponding bronchus.

Fig. A - Tramline sign - dilated, thickened bronchial walls (blue arrows)

Fig. B - Signet ring - The bronchi (red arrows) are larger than their corresponding arteries (white arrows)

#pulmonary

#radiology

References:

1. Ledda RE, Balbi M, Milone F, Ciuni A, Silva M, Sverzellati N, Milanese G. Imaging in non-cystic fibrosis bronchiectasis and current limitations. BJR Open. 2021 Jul 29;3(1):20210026. doi: 10.1259/bjro.20210026. PMID: 34381953; PMCID: PMC8328081.

2. Sawada H, Kudoh R, Yokoyama A, Hagiwara A, Hiramatsu K, Kadota JI, Komiya K. Chest X-Ray Features in 130 Patients with Bronchiectasis. Diseases. 2024 Dec 10;12(12):323. doi: 10.3390/diseases12120323. PMID: 39727653; PMCID: PMC11726920.

3. Bird K, Memon J. Bronchiectasis. 2023 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28613561.

Snoring and associated conditions

Q: Which of the following (so far) is NOT found to be associated with snoring (Obstructive Sleep Apnea- OSA)? - Select one

A) Carotid atherosclerosis

B) Hypertension

C) Ischemic heart disease 

Answer: C

Although conventionally it is believed that patients with snoring, either due to OSA or simple upper airway narrowing, will develop ischemic heart disease, evidence has failed to show such an association.

In contrast, carotid atherosclerosis and hypertension are found to be very well associated with snoring.

#sleep

#ENT

#pulmonary

#cardiology

References:

1. Yeboah J, Redline S, Johnson C, et al. Association between sleep apnea, snoring, incident cardiovascular events and all-cause mortality in an adult population: MESA. Atherosclerosis 2011; 219:963.

2. Marshall NS, Wong KK, Cullen SR, et al. Snoring is not associated with all-cause mortality, incident cardiovascular disease, or stroke in the Busselton Health Study. Sleep 2012; 35:1235.

3. Jennum P, Hein HO, Suadicani P, Gyntelberg F. Risk of ischemic heart disease in self-reported snorers. A prospective study of 2,937 men aged 54 to 74 years: the Copenhagen Male Study. Chest 1995; 108:138.

ETT and neck movement

Q: Extension of neck (Chin up) will cause Endotracheal tube (ETT) to migrate? - Select one

A) up 

B) down

Answer: A

Extending the neck (Chin up) causes ETT to migrate up, and flexion of the neck (Chin down) causes ETT to migrate down.

Rule:

Chin up - ETT up

Chin down - ETT down

Clinical application: During tracheostomy, operator has to extend the neck. This may inadvertently extubate the patient prior to insertion of tracheostomy tube. 

#procedures

#ENT

References:

1. Tsukamoto M, Yamanaka H, Hitosugi T, Yokoyama T. Endotracheal Tube Migration Associated With Extension During Tracheotomy. Anesth Prog. 2020 Spring;67(1):3-8. doi: 10.2344/anpr-66-04-05. PMID: 32191508; PMCID: PMC7083118.

2. Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD. Head rotation, flexion, and extension alter endotracheal tube position in adults and children. Can J Anaesth. 2009 Oct;56(10):751-6. doi: 10.1007/s12630-009-9158-y. Epub 2009 Jul 29. PMID: 19639372.

TRAS

Case: 54 years old male with history of kidney transplant 10 months ago presented to Emergency department with accelerated hypertension and flash pulmonary edema. On examination, an abdominal bruit over the transplanted site is heard. What is the most probable diagnosis?

Answer: TRAS (Transplant renal artery stenosis)

TRAS can occur in up to one in four renal transplanted recipient patients. It occurs at the site of the renal artery anastomosis. Interestingly, it can also occur in the donor's renal artery or the feeding native artery. The usual causes are difficulty during transplants, causing flow limitation through vascular clamping, kinking, or angulation of the artery. Major clinical signs are:  

• Worsening hypertension
• Unexplained and persistent Hypokalemia (secondary hyperaldosteronism)
• Kidney function decline
• Episodes of flash pulmonary edema
• Abdominal bruit over the allograft (may or may not be present)

The risk factors are

• Difficulties in organ procurement 
• Poor/complex operative techniques 
• Atherosclerotic disease
• Cytomegalovirus infection
• Delayed allograft function 

 Fortunately, it is reversible. 

#nephrology

#transplantation

References:

1. Audard V, Matignon M, Hemery F, et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006; 6:95.

2. Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004; 15:134.

3. Voiculescu A, Schmitz M, Hollenbeck M, et al. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant 2005; 5:1731.

4. Pouria S, State OI, Wong W, Hendry BM. CMV infection is associated with transplant renal artery stenosis. QJM 1998; 91:185.

hallucinations in psychiatric disorders

Q: Which hallucination is more common in psychiatric illness? - select one

A) Auditory

B) Visual 

Answer: A

Auditory hallucinations are almost twice as common and can accompany the visual hallucinations. Most visual hallucinations are complex and usually disturbing and lack insight. 

A complete psychiatric evaluation is required.

#psychiatry

References:

1. Bowman KM, Raymond AF. A statistical study in the manic-depressive psychoses. Am J Psychiatry 1931; 88:299.

2. Black DW, Nasrallah A. Hallucinations and delusions in 1,715 patients with unipolar and bipolar affective disorders. Psychopathology 1989; 22:28.

3. Goodwin DW, Alderson P, Rosenthal R. Clinical significance of hallucinations in psychiatric disorders. A study of 116 hallucinatory patients. Arch Gen Psychiatry 1971; 24:76.

Hemothorax and hematocrit

Q: How is Hemothorax defined based on Hematocrit?

Answer: A pleural effusion with a hematocrit value of more than 50% of that of the circulating hematocrit is considered a hemothorax.

#pulmonary

References:

1. DiVietro ML, Huggins JT, Angotti LB, Kummerfeldt CE, Nestor JE, Doelken P, Sahn SA. Pleural Fluid Analysis in Chronic Hemothorax: A Mimicker of Infection. Clin Med Insights Case Rep. 2015 Aug 10;8:71-6. doi: 10.4137/CCRep.S12404. PMID: 26309422; PMCID: PMC4533848.

2. Zeiler J, Idell S, Norwood S, Cook A. Hemothorax: A Review of the Literature. Clin Pulm Med. 2020 Jan;27(1):1-12. doi: 10.1097/CPM.0000000000000343. Epub 2020 Jan 10. PMID: 33437141; PMCID: PMC7799890.

complex sleep-related behaviors

Q: 32 years old male is brought to the ED after a Motor Vehicle Accident (MVA). Patient does not remember driving. Per his wife, he went to bed normally, but she was awakened with a police call that her husband was in an MVA on highway. The patient was found by police at the accident site behind a vehicle, only in night gown without any shoes or slippers. Patient recalled that the very last thing he did was going to bed at his home. He acknowledges that recently he has increased the dose of his sleep medicine on his own. The patient was diagnosed with complex sleep-related behaviors. What are the few complex sleep-related behaviors with insomnia meds?

Answer:

Complex sleep-related behaviors are common and very underappreciated. They are common with higher doses of all insomnia meds, but the most described culprits are

• zolpidem
• zaleplon
• eszopiclone
• triazolam

Patients may perform various activities outside of their will and may be potentially fatal (like our patient in the above case). Common activities while not awake are

• sleepwalking
• driving
• phone call
• eating
• sex 
• swimming

Interestingly, young people are prone to such incidents more than elderly people.

#sleep

#pharmacology

#psychiatry

References:

1. US Food and Drug Administration (FDA). FDA adds boxed warning for risk of serious injuries caused by sleepwalking with certain prescription insomnia medicines. FDA Drug Safety Communication, April 30, 2019. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-risk-serious-injuries-caused-sleepwalking-certain-prescription-insomnia (Accessed on March 31, 2025).

2. Chen CS, Huang MF, Hwang TJ, et al. Clinical correlates of zolpidem-associated complex sleep-related behaviors: age effect. J Clin Psychiatry 2014; 75:e1314.

3. Chen LF, Lin CE, Chou YC, et al. A comparison of complex sleep behaviors with two short-acting Z-hypnosedative drugs in nonpsychotic patients. Neuropsychiatr Dis Treat 2013; 9:1159.

4. Tsai JH, Yang P, Chen CC, et al. Zolpidem-induced amnesia and somnambulism: rare occurrences? Eur Neuropsychopharmacol 2009; 19:74.

5. Hwang TJ, Ni HC, Chen HC, et al. Risk predictors for hypnosedative-related complex sleep behaviors: a retrospective, cross-sectional pilot study. J Clin Psychiatry 2010; 71:1331.

equi-osmolarity of Mannitol vs. Salt bomb

Q: In the treatment of increased intracranial pressure (ICP), what is the equivalency of 23.4% of NaCl and Mannitol in terms of similar osmolar effect?

Answer: To be precise, 0.686 ml of 23.4% NaCl is equiosmolar to 1 gram/kg of 20% mannitol in effect. 

The usual dose is 30-50 ml of 23.4% NaCl or 50-70 grams of mannitol q3-q6 hours as needed. Dose can be adjusted per clinical situation and lab osmolarity findings.

#neurology

#pharmacology

References:

1. Ch. Lazaridis, R. Neyens, J. Bodle - High-osmolality saline in neurocritical care systematic review and meta-analysis - Crit Care Med, 41 (2013), pp. 1353-1360

2. Gisela Llorente, Maria Claudia Niño de Mejia, Mannitol versus hypertonic saline solution in neuroanaesthesia, Colombian Journal of Anesthesiology, Volume 43, Supplement 1, 2015, Pages 29-39,

ISSN 2256-2087, https://doi.org/10.1016/j.rcae.2014.07.010. (https://www.sciencedirect.com/science/article/pii/S2256208714000935)

Renal cyst and potassium

Case: 62 years old male presented to ED with flank pain and accelerated hypertension (HTN). He informed that his primary care doctor recently found him to have late-onset HTN. In the last few months, he has continued to have potassium issues in his lab work for no reason. The only positive finding so far, is a simple renal cyst on abdominal ultrasound, regarded as an incidental finding by the radiologist. If a simple cyst of the kidney becomes symptomatic, it tends to cause? - Select one

A) hyperkalemia

B) hypokalemia

Answer: B

The finding of a renal cyst on ultrasound is usually benign and an incidental finding. But, if it enlarges in size, it may become a cause of late-onset hypertension. The reason is persistent pain, discomfort, and possible excess renin secretion. This should be treated as secondary HTN, which many times presents as an acute rise in blood pressure in a normotensive person. 

These patients tend to have persistent hypokalemia, which remains unexplained due to any other cause.

#nephrology

#electrolytes

References:

1. Ferrari P. The challenge of renal cystic disease and its association with hypertension, age and abnormal potassium handling. J Hypertens. 2007 Jul;25(7):1347-9. doi: 10.1097/HJH.0b013e32814db544. PMID: 17563553.

2. Gamakaranage CS, Rodrigo C, Jayasinghe S, Rajapakse S. Hypokalemic paralysis associated with cystic disease of the kidney: case report. BMC Nephrol. 2011 Apr 18;12:16. doi: 10.1186/1471-2369-12-16. PMID: 21501478; PMCID: PMC3095547.

BP from lower extremities

Q: Blood Pressure (BP) obtained from the lower extremity is usually _______________ than the BP obtained from the arm? - select one

A) higher

B) lower

Answer: A

Although undesirable, BP from the lower extremities can be obtained if needed, particularly in End-Stage Renal Disease (ESRD) patients with vascular fistulae. Patients with a known history of coarctation of the aorta may also require that.

Systolic blood pressure in the lower extremity is usually higher than in the upper extremity (measured from the brachial artery). This is true for both the calf and the ankle. On an average, the difference is about 10 mmHg higher in the calf and 17 mmHg higher in the ankle.

While obtaining BP in the lower extremity, the cuff center should align with the popliteal artery. 

#cardiology

#procedures

References:

1. Sheppard JP, Lacy P, Lewis PS, Martin U; Blood Pressure Measurement Working Party of the British and Irish Hypertension Society. Measurement of blood pressure in the leg-a statement on behalf of the British and Irish Hypertension Society. J Hum Hypertens. 2020 Jun;34(6):418-419. doi: 10.1038/s41371-020-0325-5. Epub 2020 Apr 22. PMID: 32322006; PMCID: PMC7299841.

2. McDonagh STJ, Sheppard JP, Warren FC, Boddy K, Farmer L, Shore H, Williams P, Lewis PS, Baumber R, Fordham J, Martin U, Aboyans V, Clark CE; INTERPRESS-IPD Collaborators. Arm Based on LEg blood pressures (ABLE-BP): can systolic leg blood pressure measurements predict systolic brachial blood pressure? Protocol for an individual participant data meta-analysis from the INTERPRESS-IPD Collaboration. BMJ Open. 2021 Mar 19;11(3):e040481. doi: 10.1136/bmjopen-2020-040481. PMID: 33741659; PMCID: PMC7986760.

SJS/TEN and Na

Q: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) usually causes? - select one

A) hypernatremic dehydration

B) hyponatremic dehydration

Answer: B

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a serious and potentially fatal mucocutaneous drug reaction, characterized by extensive necrosis and detachment of the epidermis due to massive keratinocyte apoptosis. It usually starts as a prodrome of fever and influenza-like symptoms followed in one to three days by an eruption of ill-defined, coalescing, erythematous macules with atypical target lesions. As the disease progresses, vesicles and bullae form, and the skin begins to slough within days. Mucosal involvement occurs in over 90 percent of cases.

Morbidity (and mortality) occurs due to massive loss of fluids, electrolyte imbalance, hypovolemic shock with hyponatremic dehydration, sepsis, and multiple system organ failure (MSOF). These patients are usually managed in a burn unit because of extensive skin detachment. 

#dermatology

References:

1. Hung CC, Liu WC, Kuo MC, Lee CH, Hwang SJ, Chen HC. Acute renal failure and its risk factors in Stevens-Johnson syndrome and toxic epidermal necrolysis. Am J Nephrol. 2009;29(6):633-8. doi: 10.1159/000195632. Epub 2009 Jan 21. PMID: 19155617.

2. Huang SC, Tsai SJ. Hyponatremia and Stevens-Johnson syndrome in a patient receiving carbamazepine. Gen Hosp Psychiatry. 1995 Nov;17(6):458-60. doi: 10.1016/0163-8343(95)90049-7. PMID: 8714810.

3. Shah H, Parisi R, Mukherjee E, Phillips EJ, Dodiuk-Gad RP. Update on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Diagnosis and Management. Am J Clin Dermatol. 2024 Nov;25(6):891-908. doi: 10.1007/s40257-024-00889-6. Epub 2024 Sep 15. PMID: 39278968; PMCID: PMC11511757.

Mx of Delirium Tremens

Q: In refractory delirium tremens(R-DT), phenobarbital should be prescribed ___________ benzodiazepine. - Select one

A) With

B) Without

Answer: A

The probable pathophysiology behind refractory delirium tremens is the low endogenous GABA (gamma-aminobutyric acid) concentrations or acquired conformational changes in the GABA receptor.

Barbiturates and Benzodiazepines work synergistically in R-DT. Barbiturates increase the duration of channel opening, and benzodiazepines increase the frequency of GABA chloride channel opening.

Phenobarbital is the most effective barbiturate in refractory delirium tremens and is often referred to as 'phenobarb-coma.' It should be combined with benzodiazepine and monotherapy with phenobarb should be avoided.

#neurology

#toxicity

#pharmacology

References:

1. Lee CM, Dillon DG, Tahir PM, Murphy CE 4th. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:515.

2. Grover S, Ghosh A. Delirium Tremens: Assessment and Management. J Clin Exp Hepatol. 2018 Dec;8(4):460-470. doi: 10.1016/j.jceh.2018.04.012. Epub 2018 May 5. PMID: 30564004; PMCID: PMC6286444.

3. Kafle P, Mandal AK, Shrestha B, Bhattrai B, Bhandari M, Bhagat S, Shankar Kar B, Sharma D, Gayam V. Twenty-Eight-Day-Long Delirium Tremens. J Investig Med High Impact Case Rep. 2019 Jan-Dec;7:2324709619847228. doi: 10.1177/2324709619847228. PMID: 31053040; PMCID: PMC6505229.

gland enlargement in alcoholic cirrhosis

Q: Which of the following gland enlargement can be seen in advanced alcohol-associated cirrhosis? - select one

A) Parotid gland 

B) Salivary Gland

Answer: A

This question aims to raise awareness of the clinical importance of physical exams and "a physician touch" in clinical medicine.

Even various stigmata of liver failure can guide physicians to the specific etiology of cirrhosis. Three primary organ dysfunctions are highly likely to be seen in advanced alcohol-associated cirrhosis (though they  can be present in other types of cirrhosis)

• Dupuytren contractures
• Parotid gland enlargement
• Testicular atrophy

Although parotid gland enlargement in chronic alcoholism is known since alcohol was known to humankind, it was first reported in present-day literature in 1957 and has been consistently described.

#hepatology

#physical-exam

References:

1. Stanley J. Wolfe, M.D., W. H. J. Summerskill, D.M., M.R.C.P., and Charles S. Davidson, M.D.- Parotid Swelling, Alcoholism and Cirrhosis, Published March 14, 1957, N Engl J Med 1957; VOL. 256 NO. 11,256:491-495, DOI: 10.1056/NEJM195703142561103

2. Dutta SK, Dukehart M, Narang A, Latham PS. Functional and structural changes in parotid glands of alcoholic cirrhotic patients. Gastroenterology. 1989 Feb;96(2 Pt 1):510-8. doi: 10.1016/0016-5085(89)91578-3. PMID: 2910764.

Onn discovery of cryoprecipitate

A quote from history on the discovery of cryoprecipitate

Cryoprecipitate is cold-insoluble portion of plasma that precipitates when FFP has been thawed between 1- 6 °C. It is rich in fibrinogen and factor VIII. It also contains von Willebrand factor (vWF) and factor XIII.

"I made a mistake in an experiment, and instead of putting frozen plasma back in the freezer at the end of the day's experiment, I instead stuck it in the refrigerator. When I came in the next morning, there was all this junk in the bottom of the tube which I spun out, and I used the plasma for my experiment. My experiment didn't work because there was no Factor VIII in it. And I went back and fished the junk out of the trash and assayed the junk and got these outrageously high values for Factor VIII in the junk, and neither Charlie nor I believed it, and so it was one of those things. And sure enough, about a year later Judith Graham Pool discovered cryoprecipitate".

#hematology

Reference: 

Resnik, Susan (1999). Blood Saga: Hemophilia, AIDS, and the Survival of a Community. Berkeley: University of California Press. pp. 40–41

CGA

Q: What are the six domains of comprehensive geriatric assessment (CGA) in oncology patients?

Answer: More than half of the new cases and 70 percent of mortality from cancer occur in patients ≥65 years of age.

Many oncologists perform comprehensive geriatric assessments (CGAs) and make a shared decision about the extent of oncology treatment. 

Consensus guidelines from the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the International Society for Geriatric Oncology (SIOG) recommend its use. Over time, there were many modifications done either individually by a physician or by practice groups, but overall, the following domains of CGA should be considered:

• Functional status
• Comorbidity
• Nutrition 
• Medication review
• Psychological state and social support
• Cognitive function

#oncology

References:

1. Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†. Ann Oncol 2015; 26:288.

2. Mohile SG, Dale W, Somerfield MR, Hurria A. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology Summary. J Oncol Pract 2018; 14:442.

3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Older adult oncology. https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf 

4. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005; 104:1998.