Multiple Small Feedings of the Mind a.k.a. 28 days on Gmed1 Ward Attending, Feb 18 – Mar 16, 2008 Norm Jensen MD MS Professor (emeritus) CHS.

Multiple Small FeedingsMultiple Small Feedingsof the Mindof the Mind

a.k.a. 28 days on Gmed1a.k.a. 28 days on Gmed1

Ward Attending, Feb 18 – Mar 16, 2008Ward Attending, Feb 18 – Mar 16, 2008

Norm Jensen MD MSNorm Jensen MD MSProfessor (emeritus) CHSProfessor (emeritus) CHS

Intended Learning Intended Learning OutcomesOutcomes

Tell ‘em what yer gonna tell ‘emTell ‘em what yer gonna tell ‘em Overview of a month on Gmed 1Overview of a month on Gmed 1 4 selected cases4 selected cases

– ““Internal medicine trauma” (2)Internal medicine trauma” (2)– ““Drug Rash” reconsideredDrug Rash” reconsidered– Pneumonia that won’t go awayPneumonia that won’t go away

Case inventory with pearlsCase inventory with pearls

Feb 17 – March 16, 2008Feb 17 – March 16, 2008Patients admitted Patients admitted

4 inherited4 inherited 47 new admissions47 new admissions 7 TLC transfers7 TLC transfers Average LoS = 6.7 days (2-38)Average LoS = 6.7 days (2-38)

Case 1Case 1

64 y/o homeless man, verbally 64 y/o homeless man, verbally aggressive, labile mood, old MI, aggressive, labile mood, old MI, LE arterial insufficiency, heavy LE arterial insufficiency, heavy tobacco use; transferred after 5 tobacco use; transferred after 5 days in a Rockford hospital for days in a Rockford hospital for care of foot injury of ~ 2 week care of foot injury of ~ 2 week duration. Surgery refused to duration. Surgery refused to take him in ER.take him in ER.

Case 1

Not Case 1Not Case 1

Case twoCase two

49 y/o man referred from Beaver Dam 49 y/o man referred from Beaver Dam hospital for hypothermia and frostbite hospital for hypothermia and frostbite after out drinking with a friend. Stopped after out drinking with a friend. Stopped by police on way home, ran from car in by police on way home, ran from car in light clothing, lay in field near farm house light clothing, lay in field near farm house in 10° F weather, fell asleep ~ 6.5 hours, in 10° F weather, fell asleep ~ 6.5 hours, awoke unable to walk. Crawled to house awoke unable to walk. Crawled to house where residents called 911. Hx of AODA, where residents called 911. Hx of AODA, Reynaud’s ?, and hep C.Reynaud’s ?, and hep C.

Case two, cont.Case two, cont.

Beaver Dam ER: Core temp 89.9°, combative, Beaver Dam ER: Core temp 89.9°, combative, foam around mouth, CK 719, Troponin 0.7 , atrial foam around mouth, CK 719, Troponin 0.7 , atrial fibrillation RVR. Rx: rapid external warming of fibrillation RVR. Rx: rapid external warming of body and extremities, transfer to UWHbody and extremities, transfer to UWH

UWH: Cooperative, throbbing pain in fingers, UWH: Cooperative, throbbing pain in fingers, temp 97.5°, NSR 102, erythema abdomen, mottled temp 97.5°, NSR 102, erythema abdomen, mottled cyanosis anterior knees, fingers, toes and heels, cyanosis anterior knees, fingers, toes and heels, CK max 2724, troponin 0.4, urine tox. cocaine +, CK max 2724, troponin 0.4, urine tox. cocaine +, alcohol -.alcohol -.

Case two, cont.Case two, cont.

Photos not case 2Photos not case 2

Not Not case case

2 2 photphot

oo

Literature search = frostbite, human, Literature search = frostbite, human, english, adults > 19, core clinical english, adults > 19, core clinical

journalsjournals

Mesh 1449Mesh 1449 Major Mesh 1180Major Mesh 1180 RCTs = 0RCTs = 0 Clinical trials = 1Clinical trials = 1 Meta-analysis = 0Meta-analysis = 0 Reviews = 2Reviews = 2

89.6 82.4

Axonal degeneration = Numbness, dysesthesia, cutaneous vasomotor instability; sensitivity to cold may persist for years

Chilblains (pernio) = Pruritic patches of erythema and cyanosis, especially on hands and feet, that may blister, ulcerate, scar or atrophy

Cold-contact adhesion = Erosion or ulcer on forcible separation

Frostbite = Superficial Pallor, edema, blistering, desquamation, deep hemorrhagic blisters and anesthesia, followed later by hyperesthesia, ulceration and gangrene

Frostnip = Transient numbness and tingling without residual tissue damage

Immersion syndrome (trench foot) = Alternating vasoconstriction (cold, pallor, cyanosis and pulselessness) and vasodilatation (warmth, erythema and edema), ecchymosis, blistering, lymphangitis, cellulitis, thrombophlebitis, gangrene

Local cold-induced injuries

FrostbiteFrostbiteOnly one RCT in MedlineOnly one RCT in Medline

TwomeyTwomey JA JA, , PeltierPeltier GL GL, , ZeraZera RT RT.. J Trauma. 2005 Dec;59(6):1350-4; J Trauma. 2005 Dec;59(6):1350-4;

discussion 1354-5. discussion 1354-5. – An open-label prospective case series to An open-label prospective case series to

evaluate the safety and efficacy of tissue evaluate the safety and efficacy of tissue plasminogen activator (tPA) in treatment plasminogen activator (tPA) in treatment of severe frostbite. of severe frostbite.

– Hennepin County Hospital, MPLS, Hennepin County Hospital, MPLS, MNMN

MethodsMethods

Historical controlsHistorical controls– Consecutive trauma center patients with Consecutive trauma center patients with

severe frostbite, 1985-1989severe frostbite, 1985-1989– N = 16, 1 woman, age 26 – 60N = 16, 1 woman, age 26 – 60– 22 foot injuries, 14 hand injuries22 foot injuries, 14 hand injuries– All imaged with Tc-99m for arterial flowAll imaged with Tc-99m for arterial flow– Blinded review of nuclear vascular scans Blinded review of nuclear vascular scans

by 3 radiologistsby 3 radiologists

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

MethodsMethods

Intervention patientsIntervention patients– Consecutive patients considered 1989-Consecutive patients considered 1989-

2003 2003 – Severe frostbite Severe frostbite – Age 18 - 75Age 18 - 75

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

MethodsMethods

InclusionInclusion– No improvement on rapid rewarming in No improvement on rapid rewarming in

tepid water (38-42° C) for 15-20 min.tepid water (38-42° C) for 15-20 min.– Absent Doppler pulses in limbs and/or Absent Doppler pulses in limbs and/or

digitsdigits– No perfusion on Tc-99mm 3-phase scanNo perfusion on Tc-99mm 3-phase scan

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

MethodsMethods

ExlusionExlusion– Severe hypertensionSevere hypertension– Recent trauma, stroke or bleeding disorderRecent trauma, stroke or bleeding disorder– PregnancyPregnancy– Mental incapacityMental incapacity– Drug or alcohol intoxicationDrug or alcohol intoxication– Repeated freeze-thaw cyclesRepeated freeze-thaw cycles– > 48 hours of cold exposure> 48 hours of cold exposure

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

MethodsMethods

Treatment group 1 n = 6Treatment group 1 n = 6

– 0.075 mg/kg/hr 0.075 mg/kg/hr intra-arteriallyintra-arterially x 6 hours x 6 hours

– Flow scanned again after treatmentFlow scanned again after treatment– If no flow, treatment repeatedIf no flow, treatment repeated

Treatment group 2 n = 7Treatment group 2 n = 7– After recognizing benefits in untreated limbsAfter recognizing benefits in untreated limbs

– Trial & error varying Trial & error varying IVIV doses seeking optimal doses seeking optimal

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

MethodsMethods

Treatment group 3 n = 6Treatment group 3 n = 6– 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr

x 6 hrs up to 100 mg totalx 6 hrs up to 100 mg total

All started on IV heparin immediately All started on IV heparin immediately after tPA to PTTx2, + warfarin 2-5 d after tPA to PTTx2, + warfarin 2-5 d after tPA x 4 wks.after tPA x 4 wks.

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

Results, controlsResults, controls

Historical controlsHistorical controls, n = 16, n = 16– Generalized or focal hyperemia present in Generalized or focal hyperemia present in

all on scintiscanall on scintiscan– 7 had little or no perfusion distal to a 7 had little or no perfusion distal to a

“cutoff” point on scintiscan“cutoff” point on scintiscan– All 7 needed amputationAll 7 needed amputation– ““Cutoff” level predicted amputation level Cutoff” level predicted amputation level

and standard care didn’t modify that.and standard care didn’t modify that.

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

Pre-treatment “typical”Pre-treatment “typical”

Results of tPAResults of tPA

Treatment groups 1, 2, & 3 lumped Treatment groups 1, 2, & 3 lumped for data reporting. N = 19for data reporting. N = 19

174 digits at risk for amputation174 digits at risk for amputation 2 tPA complications required d/c tPA2 tPA complications required d/c tPA

– Both having intra-arterial tPABoth having intra-arterial tPA– 1 bleeding from arterial puncture sites1 bleeding from arterial puncture sites– 1 hematuria, rx held until resolved1 hematuria, rx held until resolved

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

Results of tPAResults of tPA

Treatment groups 1, 2, & 3 lumped for data Treatment groups 1, 2, & 3 lumped for data reporting. N = 19reporting. N = 19

16 / 19 “responded” to tPA16 / 19 “responded” to tPA 33 / 174 digits required some amputation33 / 174 digits required some amputation

– Including 10 digits from one with 60 hours Including 10 digits from one with 60 hours exposure who secondarily clotted both limbs exposure who secondarily clotted both limbs after tPAafter tPA

– 1 other “complete failure” attributed to 1 other “complete failure” attributed to prolonged exposureprolonged exposure

– NNT 1/1-0.19 = 1.2NNT 1/1-0.19 = 1.2

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

Results of tPAResults of tPA

J Trauma. 2005 J Trauma. 2005 Dec;59(6):1350-4Dec;59(6):1350-4

Before tPABefore tPA After tPAAfter tPA

Frostbite Rx Frostbite Rx standardstandard

Rapid re-warmingRapid re-warming Assess appearance & Doppler pulsesAssess appearance & Doppler pulses Early phase Tc-99m scintiscan (or arteriography)Early phase Tc-99m scintiscan (or arteriography) tPA 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr to tPA 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr to

100 mg total over 4-6 hrs.100 mg total over 4-6 hrs. Heparin 3-5 daysHeparin 3-5 days Warfarin INR 2 for 4 weeksWarfarin INR 2 for 4 weeks Opioids for pain / ibuprofen 400-600 q.i.d.Opioids for pain / ibuprofen 400-600 q.i.d. Light dressings with topical antimicrobialsLight dressings with topical antimicrobials No ambulation on frostbitten feetNo ambulation on frostbitten feet

Case 3Case 3

42 y/o man previously healthy except for 42 y/o man previously healthy except for depression was referred from Monroe depression was referred from Monroe Clinic for abdominal pain, non-itchy rash Clinic for abdominal pain, non-itchy rash (face → trunk) fever 100.4 max, abnormal (face → trunk) fever 100.4 max, abnormal liver tests beginning one day after liver tests beginning one day after beginning new antidepressant, duloxetine. beginning new antidepressant, duloxetine. Rx Rx vancomycin, acyclovir and ceftriaxone, and transferred.

Alk Phos 168, AST 90, ALT 155

Not Not Case 3 Case 3 photosphotos

Not case 3 photoNot case 3 photo

Varicella in adultsVaricella in adults Highly contagious: respiratory droplets, Highly contagious: respiratory droplets,

vesicle fluid direct contactvesicle fluid direct contact Incubation 14 – 16 (10 – 21) daysIncubation 14 – 16 (10 – 21) days Vesicles in crops over <4 daysVesicles in crops over <4 days

Vesicles → pustules → crustsVesicles → pustules → crusts Contagious 48 hr before rash until all Contagious 48 hr before rash until all

lesions fully crusted (~=< 6 days).lesions fully crusted (~=< 6 days). >90% adults “immune”, ? Reinfection?>90% adults “immune”, ? Reinfection? Immunization kids since 1995Immunization kids since 1995 > age 20 = < 5% cases & 55% deaths> age 20 = < 5% cases & 55% deaths

Varicella in adultsVaricella in adults

ComplicationsComplications– Pneumonia 1:400, 1-6 days after rash, most Pneumonia 1:400, 1-6 days after rash, most

hospitalizations, 10-30% mortality, 50% if hospitalizations, 10-30% mortality, 50% if ventilation needed.ventilation needed.

– Encephalitis 1:4,000, diffuse, 10% die, 15% Encephalitis 1:4,000, diffuse, 10% die, 15% permanent deficits.permanent deficits.

– Hepatitis, uncommon if immune competentHepatitis, uncommon if immune competent often fatal if immune incompetentoften fatal if immune incompetent

– IF immune compromised, everything is worseIF immune compromised, everything is worse

Case 4Case 4

38 y/o woman, mother of 2 with concurrent 38 y/o woman, mother of 2 with concurrent respiratory illness, accountant, on OCPrespiratory illness, accountant, on OCP

3 wk ill, burning anterior low neck, and 3 wk ill, burning anterior low neck, and DOE “like something sitting on chest”, DOE “like something sitting on chest”, chills, anorexia, sudden onset after snow chills, anorexia, sudden onset after snow shovellingshovelling

1 week fever, dry cough, and pleurisy on 1 week fever, dry cough, and pleurisy on admissionadmission

First treated with PPI, then AzithromycinFirst treated with PPI, then Azithromycin

Case 4Case 4 PE = healthy appearing, good color, no PE = healthy appearing, good color, no

distress, 124/80, HR 128 reg., RR 22 easy, 96% distress, 124/80, HR 128 reg., RR 22 easy, 96% RA, fine rRA, fine rââles bases, les bases, P2 P2

LAB = WBC 8,500 nl. ESR 81, CRP 3, d-Dimer LAB = WBC 8,500 nl. ESR 81, CRP 3, d-Dimer 0.6, Alk Phos 354 (<131), GGT 221 (<40), AST 0.6, Alk Phos 354 (<131), GGT 221 (<40), AST 58 (<41), ALT 115 (<66), Lipase 327 (<286), 58 (<41), ALT 115 (<66), Lipase 327 (<286), ANA + >1:640, +anti HBC, low iron and ferritin, ANA + >1:640, +anti HBC, low iron and ferritin, and slightly increased ceruloplasmin 71 (17-and slightly increased ceruloplasmin 71 (17-54), haptoglobin, C3, and 3x increase in IGM.54), haptoglobin, C3, and 3x increase in IGM.

ECG = right heart strain patternECG = right heart strain pattern

Case 4Case 4

CXR bilat airspace disease lower lobesCXR bilat airspace disease lower lobes

CT ANGIO CHEST-PE PROTOCOL = Extensive bilateral patchy airspace disease with a basilar and peripheral predominance. No emboli.

Case 4 chest xray

Case 4 lung CT, PE protocol

Case 4 lung CT, PE protocol

Case 4 lung CT, PE protocol

Case 4 lung CT, PE protocol

Case 4 lung CT, PE protocol

Case 4 lung CT, PE protocol

Case 4Case 4

LE dopplers negative for DVTLE dopplers negative for DVT

Bronchoscopy = normal appearance of Bronchoscopy = normal appearance of airwaysairways

BAL = 2000 cells / uL, 80% monosBAL = 2000 cells / uL, 80% monos BX = BX = Organizing pneumonia. RSV+

DFA

Case 4: Rx and Hospital Case 4: Rx and Hospital coursecourse

RX: RX: – Fractionated heparinFractionated heparin– ABX for complex CAP = Amp / ABX for complex CAP = Amp /

sulbactam, vancomycon, moxifloxacin sulbactam, vancomycon, moxifloxacin narrowed to moxifloxacin after 3 days.narrowed to moxifloxacin after 3 days.

Daily improvement. DC’d on day 5, Daily improvement. DC’d on day 5, 50% improved by symptoms on 40 50% improved by symptoms on 40 mg prednisone / day + TMP/SMZ mg prednisone / day + TMP/SMZ prophylaxisprophylaxis

Case 4 Adult RSV Case 4 Adult RSV pneumoniapneumonia

Typical chest imaging Typical chest imagingCONCLUSION: The most common high-CONCLUSION: The most common high-

resolution CT findings in patients with resolution CT findings in patients with respiratory syncytial virus pneumonia respiratory syncytial virus pneumonia after bone marrow transplantation consist after bone marrow transplantation consist of small centrilobular nodules and of small centrilobular nodules and multifocal areas of consolidation and multifocal areas of consolidation and ground-glass opacities in a bilateral ground-glass opacities in a bilateral asymmetric distribution.asymmetric distribution.

AJR Am J Roentgenol. 2004 May;182(5):1133-7. AJR Am J Roentgenol. 2004 May;182(5):1133-7.

Case 4Case 4 Adult RSV pneumonia Adult RSV pneumonia

5 year case series teaching hospital 5 year case series teaching hospital BarcelonaBarcelona

338 consecutive patients with CAP338 consecutive patients with CAP 61 (18%) viruses detected61 (18%) viruses detected

– 30 (9%) virus with other organisms30 (9%) virus with other organisms– 31 (9%) only viruses31 (9%) only viruses

16 Influenza A16 Influenza A 7 Influenza B7 Influenza B 2 Parainfluenza 1, 2, or 32 Parainfluenza 1, 2, or 3 4 R S V (1% all)4 R S V (1% all) 2 Adenovirus2 Adenovirus

CHEST 2004;125:1343-51CHEST 2004;125:1343-51

Case 4 Adult RSV Case 4 Adult RSV pneumoniapneumonia

4 year case series at Rochester (NY) 4 year case series at Rochester (NY) GeneralGeneral

2,514 respiratory infections2,514 respiratory infections 1,148 prospective: 608 healthy, 540 high risk1,148 prospective: 608 healthy, 540 high risk 1,388 hospitalized agreed 1,388 hospitalized agreed

– RSV 244: 102 prospective, 142 hospitalizedRSV 244: 102 prospective, 142 hospitalized– vs Influenza A in 198vs Influenza A in 198

RSV 3 – 7 % healthy / year, 4-10 high riskRSV 3 – 7 % healthy / year, 4-10 high risk RSV admissions = 11% pneumonia, 11% COPD, 5% RSV admissions = 11% pneumonia, 11% COPD, 5%

CHF, and 7% asthmaCHF, and 7% asthma Death rate for hospitalized patients with RSV = 8%Death rate for hospitalized patients with RSV = 8%

NEJM 2005;352:1749-59NEJM 2005;352:1749-59

SeasonSeason H1N1H1N1 H3N2H3N2 BB Tot FluTot Flu RSVRSV

1990-11990-1 19881988 60336033 1754917549 2557025570 1694716947

91-291-2 65186518 4592845928 566566 5301253012 1782517825

92-392-3 11901190 1989219892 1903019030 4011240112 1546415464

93-493-4 173173 4892348923 404404 4950049500 1758117581

94-594-5 572572 3376733767 71297129 4146841468 1831218312

95-695-6 1472714727 2360523605 75097509 4584145841 1926219262

96-796-7 00 5593755937 1260912609 6854668546 1710017100

97-897-8 6666 7070170701 649649 7141671416 1646116461

98-998-9 293293 5536755367 96989698 6535865358 1727317273

MeanMean 2,8362,836 40,01740,017 8,3498,349 51,20351,203 17,35817,358

CDC: USA Influenza & RSV CDC: USA Influenza & RSV Mortality, modeled Mortality, modeled mathematically mathematically JAMA 2008;289:179-185. JAMA 2008;289:179-185.

Pneumonia & Abn. Liver Pneumonia & Abn. Liver teststests

SarcoidSarcoid VirusesViruses

– EBVEBV– Q FeverQ Fever– CMVCMV– AdenovirusAdenovirus– VaricellaVaricella

BacteriaBacteria– LegionellaLegionella– Strep milleriStrep milleri

MycoplasmaMycoplasma

BOOP / COPBOOP / COP ? RSV not yet ? RSV not yet

reportedreported

Slowly or non-resolving pneumoniaSlowly or non-resolving pneumonia Failure to resolve 50% in 2 weeks or fully in 4 Failure to resolve 50% in 2 weeks or fully in 4

weeksweeks

Host factorsHost factors– AgeAge– Loss of lung Loss of lung

elasticityelasticity– Increase in FRCIncrease in FRC– Flattening Flattening

diaphragmsdiaphragms– ↓↓T cell functionT cell function– ↓ ↓ IL1, IL2, IgMIL1, IL2, IgM– Impaired muco-Impaired muco-

ciliary clearanceciliary clearance

Co-morbid factorsCo-morbid factors– CHFCHF– DMDM– COPDCOPD– Renal failureRenal failure– Cerebrovascular Cerebrovascular

DiseaseDisease– Ethanol abuseEthanol abuse– CorticosteroidsCorticosteroids– ImmunosuppressionImmunosuppression– MalignancyMalignancy

Nonresolving Pneumonia and mimics of pneumonia. Med Nonresolving Pneumonia and mimics of pneumonia. Med Clin N America 2001;85(6) November.Clin N America 2001;85(6) November.

Slowly or non-resolving Slowly or non-resolving pneumoniapneumonia

Failure to resolve 50% in 2 weeks or Failure to resolve 50% in 2 weeks or fully in 4 weeksfully in 4 weeks

Infectious agentInfectious agent– Pneumococcal = 6 wks in Pneumococcal = 6 wks in

healthy adult, 1-4 monthshealthy adult, 1-4 months– Legionella = 2-6 monthsLegionella = 2-6 months– Mycoplasma = < 4 wksMycoplasma = < 4 wks– TBTB– FungalFungal

Histo, Blasto, Ciccidio, Histo, Blasto, Ciccidio, Aspergillus, Aspergillus, actinomycosis, nocardiaactinomycosis, nocardia

– ViralViral Influenze A & B, Influenze A & B,

Parainfluenze, RSV, Parainfluenze, RSV, adenovirusadenovirus

– PneumocystisPneumocystis

Pneumonia MimicsPneumonia Mimics– BOOP / COPBOOP / COP– Carcinoma / lymphomaCarcinoma / lymphoma– Eosinophilic pneumoniaEosinophilic pneumonia– Vasculitis, Wegener’s, Vasculitis, Wegener’s,

Churgg-StaussChurgg-Stauss– Lupus pneumonitisLupus pneumonitis– Acute alveolar hemorrhageAcute alveolar hemorrhage– Pulm alveolar proteinosisPulm alveolar proteinosis– Drug-induced infiltratesDrug-induced infiltrates– Aspiration, lipoidAspiration, lipoid– SS chest syndromeSS chest syndrome– Occupational inflitratesOccupational inflitrates– Radiation pneumonitisRadiation pneumonitis

Nonresolving Pneumonia and mimics of pneumonia. Med Nonresolving Pneumonia and mimics of pneumonia. Med Clin N America 2001;85(6) November.Clin N America 2001;85(6) November.

Slowly or non-resolving pneumoniaSlowly or non-resolving pneumonia

COP → BOOP → COP & OPCOP → BOOP → COP & OP

Clinical picture of COPClinical picture of COP– ““heterogeneous disease with insidious onset, non-specific heterogeneous disease with insidious onset, non-specific

physiologic findings, and variable radiographic patters, and physiologic findings, and variable radiographic patters, and TYPICAL histopathology.”TYPICAL histopathology.”

– 2-10 week prodrome, cough, dyspnea, abrupt onset2-10 week prodrome, cough, dyspnea, abrupt onset– PE = fine rPE = fine rââlesles– CXR & CT patchy alveolar opacities, nodular, mostly lower CXR & CT patchy alveolar opacities, nodular, mostly lower

lobes, often sub-pleural and variable ground glass opacity. lobes, often sub-pleural and variable ground glass opacity. – DX: biopsy = granulation tissue in lumen of bronchioles and DX: biopsy = granulation tissue in lumen of bronchioles and

alveolar ducts with interstitial and air-space infiltration with alveolar ducts with interstitial and air-space infiltration with mononuclear cells and macrophagesmononuclear cells and macrophages

– Clinical course highly variableClinical course highly variable– RX underlying cause; 70-80% clear with steroids, 10-15% RX underlying cause; 70-80% clear with steroids, 10-15%

progressiveprogressive

The organizing pneumonias. Current Opinion in Pulm Medicine The organizing pneumonias. Current Opinion in Pulm Medicine 2005;11:422-4302005;11:422-430

Slowly or non-resolving pneumoniaSlowly or non-resolving pneumonia

COP → BOOP → COP & SOPCOP → BOOP → COP & SOP

31-44 % associated with other diseases (SOP)31-44 % associated with other diseases (SOP) Drug reactionsDrug reactions Cocaine abuseCocaine abuse Collagen vascular diseasesCollagen vascular diseases Extrinsic alleric alveolitisExtrinsic alleric alveolitis Bacterial infectionBacterial infection HIVHIV MycoplasmaMycoplasma ViralViral MalignancyMalignancy TransplantationTransplantation Adjacent to infarcts, tumors, granulomas, pneumoniaAdjacent to infarcts, tumors, granulomas, pneumonia RadiationRadiation Fume / smoke inhalationFume / smoke inhalation Anthrax vaccination (new)Anthrax vaccination (new)

The organizing pneumonias. Current Opinion in Pulmonary The organizing pneumonias. Current Opinion in Pulmonary Medicine 2005;11:422-430Medicine 2005;11:422-430

bronchiolitis obliterans: granulation plug bronchiolitis obliterans: granulation plug (Masson body) is present within a (Masson body) is present within a bronchiolar lumen. bronchiolar lumen.

The organizing pneumonias. Current Opinion in Pulmonary The organizing pneumonias. Current Opinion in Pulmonary Medicine 2005;11:425Medicine 2005;11:425

F6/5 Feb 17 – March 16, 2008F6/5 Feb 17 – March 16, 2008Medical diagnosesMedical diagnoses

Major GI Bleed 4 (Major GI Bleed 4 (gastritisgastritis, AVM, esophageal varices, colitis?), AVM, esophageal varices, colitis?) COPD 3COPD 3 Olecranon bursitis 3Olecranon bursitis 3 Asthma 3Asthma 3 End stage liver disease 3End stage liver disease 3

– Methotrexate cirrhosisMethotrexate cirrhosis– Alcoholic liver disease, encephalopathyAlcoholic liver disease, encephalopathy– Hemophilia, HIV, HepC, encephalopathyHemophilia, HIV, HepC, encephalopathy

Pneumonia, community acquired 3, nosocomial 2Pneumonia, community acquired 3, nosocomial 2 SBO 2SBO 2

– Internal hernia of splenic flexureInternal hernia of splenic flexure– Uterine CA stage 4, post RRx, adhesions, s/post SB resection & bypassUterine CA stage 4, post RRx, adhesions, s/post SB resection & bypass

Acute gout 2 Acute gout 2 inadequate uric acid controlinadequate uric acid control Volume depletion & diarrhea, nursing home 2Volume depletion & diarrhea, nursing home 2 Peritoneal carcinomatosis 2Peritoneal carcinomatosis 2 Bariatric surgery complications 2Bariatric surgery complications 2

– Severe iron deficiencySevere iron deficiency– Hypokalemia & volume depletionHypokalemia & volume depletion

Frost bite 2Frost bite 2 Severe dementia, recurrent aspiration pneumonia 2Severe dementia, recurrent aspiration pneumonia 2 DKA 2DKA 2

F6/5 Feb 17 – March 16, 2008F6/5 Feb 17 – March 16, 2008Medical diagnosesMedical diagnoses

Acute on chronic ventillatory respiratory failureAcute on chronic ventillatory respiratory failure– Prader-Willie, aspiration, hypoventillation, hypoxia, body wall painPrader-Willie, aspiration, hypoventillation, hypoxia, body wall pain– Surgical hypopituitary, morbid obesity, OSA, rhabdomyolysisSurgical hypopituitary, morbid obesity, OSA, rhabdomyolysis

Breast CA, metastasis to femur, high risk fractureBreast CA, metastasis to femur, high risk fracture Urosepsis, self-cath on Rehab MedicineeUrosepsis, self-cath on Rehab Medicinee Fat emboli after femur fracture rod fixationFat emboli after femur fracture rod fixation CellulitisCellulitis Leaking common iliac artery anneurysmLeaking common iliac artery anneurysm VaricellaVaricella Hyperkalemia of 6.0 without signs toxicityHyperkalemia of 6.0 without signs toxicity Sertraline OD, depression, personality disorderSertraline OD, depression, personality disorder Hypoglycemia ( glucose 28) syncopeHypoglycemia ( glucose 28) syncope Surgical injury to pancreas, acute pancreatic ascitesSurgical injury to pancreas, acute pancreatic ascites IBS syndrome → Amyloid colonIBS syndrome → Amyloid colon Fall, head trauma Fall, head trauma Post laryngectomy, hypothyroid, hypoparathyroidPost laryngectomy, hypothyroid, hypoparathyroid Myositis, hepatitis, ?MCTD, parvovirus 19?Myositis, hepatitis, ?MCTD, parvovirus 19? Thrombosis of portal vein, unknown causeThrombosis of portal vein, unknown cause

Intended Learning Intended Learning OutcomesOutcomes

Tell ‘em what you told ‘emTell ‘em what you told ‘em Overview of a month on Gmed 1Overview of a month on Gmed 1 4 selected cases4 selected cases

– Frostbite, trauma for internistsFrostbite, trauma for internists– Chicken pox in adultsChicken pox in adults– RSV pneumonia RSV pneumonia – BOOP / COPBOOP / COP

PealsPeals Bariatric surgery follow up is importantBariatric surgery follow up is important Searching for GI bleeding sourceSearching for GI bleeding source Prevent gout by keeping uric acid < 6Prevent gout by keeping uric acid < 6 Olecranon bursitis needs needle drainageOlecranon bursitis needs needle drainage