MOFFITT AM REPORT – 6/6/18

A big thank you to Megan and Bennett for presenting a fascinating case of a young man with a history of cholecystectomy as a teenager, obesity ad DM2 who initially presented with likely cholangitis, who then had persistent fevers after ERCP. Pearls below!  ❤ TLC (Tim & Laura, your Chiefs!)

Post-ERCP complications

  • Ascending cholangitis: the most common infectious complication. Remember Charcot’s Pentad: 1) Fever, 2) Jaundice, 3) RUQ pain, 4) AMS, 5) Shock
  • Cholecystitis (possibly due to non-sterile contrast media entering the gall bladder)
  • Pancreatitis
  • Liver abscesses (think gram negatives seeding the liver!)
  • Perforation with bacterial peritonitis

 

 Fever of Unknown Origin

Traditional definition: Temp >38.3 for at least 3 weeks, uncertain diagnosis despite one week of inpatient evaluation

 

Differential Diagnosis:  (It’s HUUUGE but below are the most common culprits)

  1. Rheumatologic/Inflammatory
  • Sarcoidosis
  • Lupus
  • Rheumatoid Arthritis
  • Giant Cell arteritis
  • PMR
  • Still’s disease
  • Vasculitis
  • Inflammatory Bowel Disease
  • Crystal induced arthritis (don’t forget about gout, pseudogout!)
  1. Infectious
  • Abdominal abscess
  • Endocarditis
  • Syphilis
  • Mycobacterial
  • Osteomyelitis
  • Tuberculosis
  1. Neoplastic
  • Renal Cell Carcinoma
  • Solid tumors: Hepatocellular carcinoma, other tumors metastatic to the liver
  • Lymphoma
  • Leukemia
  • Atrial Myxomas: Uncommon but present with fever in ~1/3 of cases.
  1. Others
  • Drug fever: Think antibiotics, anticonvulsants, allopurinol, heparin
  • Pulmonary Emboli or venous thrombosis – may give low-grade fevers, but high spiking fevers >38.5 are less likely in PE!
  • Thyroiditis
  • Retroperitoneal Hematomas

 

Moffitt Cards Report – 6/5/18

Thank you, Vaibhav, for presenting a case of a young woman with morbid obesity, history of aortic valve endocarditis c/b MCA stroke, and massive R>L LE edema who was transferred to UCSF with shock.

Causes of widened pulse pressure:

  • Severe aortic insufficiency
    • Hypothermia causing severe systemic vasoconstriction exacerbating mild or moderate aortic regurgitation
  • Hyperdynamic circulation à Sepsis, anaphylaxis, liver failure
  • Severe intravascular hypovolemia or vasoplegia
  • Severe atherosclerotic disease – stiffening of arterioles results in amplification of pressure transmitted along peripheral vessels – so peripheral pressures are not necessarily reflective of central pressures
  • Underdampened arterial BP monitoring – resulting in systolic measurements that are artificially high and diastolic measurements that are artificially low (with a relatively unaffected MAP)

For more reading:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125196/


Causes of aortic regurgitation

  • Acute
    • Aortic dissection
    • Infective endocarditis
    • Blunt chest trauma
  • Chronic
    • Diseases that primarily affect valve leaflets
      • Bicuspid or Unicuspid aortic valve
      • Infective Endocarditis
    • Diseases that primarily affect valve annulus or aortic root
      • Connective tissue or inflammatory diseases
      • Aortopathy (Marfan, Ehlers-Danlos, osteogenesis imperfecta, Syphilis)
      • Antiphospholipid syndrome

AR review:  http://circ.ahajournals.org/content/circulationaha/112/1/125.full.pdf


Management of aortic regurgitation

  • Acute
    • Heart Rate management – drive the heart rate up in order to decrease diastolic filling time, and thus reduce regurgitant time and volume
      • Pharmacologic:
        • HOLD beta-blockade
        • Consider: dobutamine, epinephrine, isoproterenol, dopamine
      • Pacing – transcutaneous or transjugular
    • Afterload reduction
    • Evaluation for surgical management
  • Chronic – follow with serial H&P and TTEs assessing for development of symptoms, LV size and LV function.

Evernote:  https://www.evernote.com/shard/s462/sh/ca55ca83-d529-417b-86f4-42bc5286d8c8/d7e297aa4e8ef7c5db699b693305d829