Infectious Disease, week #2

Day #6:

A person with a history of E. coli sepsis (blood infection) who now has findings on a brain scan suspicious for abscess, but could also represent tumor. Abscess is more likely, so we will treat with antibiotics for 4 weeks, scan their head again, and see if there has been any response.

A person with an infection of the skull bone behind the ear on the right side, recovered, had a stroke, had a portion of skull removed to accomodate swelling, had the skull replaced and now appears to have developed an infection of the skull bone behind the left ear. Cultured the drainage and tested the susceptibility of the bacteria. Antibiotics recommended, person is recovering.

Day #7:

A person who had their hip replaced, had an infection in that hip, had the replacement removed and a new one inserted, had another infection, had the second replacement removed, now has no hip on that side and is undergoing treatment to clear... infection. They fell and now their knee is swollen too - blood from the fall, blood clot, or spreading infection? Likely from the fall. Continue antibiotics, check inflammatory markers and use ultrasound to rule out clot.

A person on dialysis with endocarditis and known brain abscesses. We helped identify the organism, choose antibiotics and he is undergoing pre-surgical workup. Kinda grumpy.

Day #8:

A Chinese immigrant who is coughing up blood. They have a lung disorder that can cause episodic blood, but there is also concern for tuberculosis (which is endemic in China). More likely to be their underlying condition (based on physical exam) - testing confirms. We set them up with pulmonary follow-up.

Day #9:

A person who arrived in liver failure due to purposeful overdose who continued to have fevers despite antibiotics. Given chest x-ray, more likely drug fever or chemical pneumonitis, but will treat with a short course of antibiotics to rule out aspiration given their altered mental status and vomiting on admission.

Day #10:

A person who has cancer and no immune cells due to chemotherapy now has a fever and trouble breathing. Chest imaging is suspicious for fungus. Lots of antibiotics started until we can clarify the nature of the infection.

A person with multiple antibiotic allergies who has an infection of the inside of the nose. There is always a concern that if inadequately treated, an infection like this will spread backwards to the brain. Broad antibiotics were started until we can grow the bug in culture and narrow them.

Still following:

The endocarditis patient from last week who has vegetations on their pacer leads. They went to surgery and had their pacemaker removed. Labs are still negative, so a 4-6 weeks course of broad spectrum antibiotics before a new device can be placed. Still unclear what their lung findings are: septic emboli vs pneumonia.

The patient with ulcerative colitis who had a blood infection and a clot in their arm... the clot was not surgically removed and they cleared the bacteria from their blood. Was discharged to complete antibiotics at home.

Jargon

Every profession has its own language that tends to make it indecipherable to outsiders. I love the medical language; it's succinct and exquisitely precise. But then, I speak doctor, fluently. In my previous post, I left out lots of details because explaining them in everyday English would have made the post three times as long. But for the curious and the fluent out there, here's the untranslated version:

Day #1:

XX year old (gender) intubated and transfered to the unit secondary to AMS and hypercarbic respiratory failure c/b ARF while being treated for LLE L2 dermatome VZV. Concern for dissemination given RLE vesicles. DFA on RLE (-). Unlikely to represent dissemination, however AMS could be VZV encephalitis. LP not possible due to L2 vesicles and body habitus. Treat empirically for 21 days.

XX year old (gender) with recurrent hospitalizations for HA, n/v. Serial LP with pleocytosis, however HSV/VZV(-). Concern for chronic meningitis. Latest LP wnl. Unlikely to be chronic infectious due to lack of exposure history. Recommend steroids and rheum workup. d/c abx.

Day #2:

XX year old (gender) with newly dx UC refractory to steroids, now on Remicade. Blood cx with GPC in clusters, PICC tip cx w/MSSA. RUE DVT from previous PIV. May d/c vanc, start cefazolin. Blood cx remain (+), RUE U/S with abscess. Now dx of septic thrombophlebitis. I&D on RUE performed, cx remain (+). Recommend thrombectomy.

Day #3:

XX year old (gender) with Waldenstroms and chronic cough x 18mo. BAL in Jan (-) on AFB smear. Now (+) for M. gordonae. Febrile to 39.1 after second chemo infusion. BAL result likely contaminant; triple therapy not benign so recommend no tx unless sx. Cough dry, not consistent with mycobacterium. Fever likely transfusion rxn.

Day #4:

XX year old (gender) hospitalised in Jan for pna/chf, transferred due to vegetations on TV and RV pacer lead. Likely cx (-) endocarditis due to abx use. Continue vanc/zosyn and call EP for lead removal. Call CT surg for valve consult. Possible that pna was actually septic emboli 2/2 large TV veggie.

Infectious Disease, week #1

For my last clinical (in-hospital) month of medical school, I have registered for an infectious diseases consult month. First I will describe what a consult service is, after that we get to the cases I saw during the first week.

Consult Service (n) - a group of physicians called by the treating doctors to answer a specific diagnostic or treatment question because of their subject-specific expertise.

It's not really different from consulting in business. You are posed a specific conundrum, you gather data, make recommendations, but have no power or authority to directly enact your plan. From a logistics standpoint, your workflow is also opposite

to a primary team. You see all your new patients in the morning and round in the afternoon.

Day #1:

A person who had altered mental status and shingles. New lesions were appearing and the primary team was worried the shingles was spreading and had become systemic (usually it's limited to a small part of the body). I decided no (lab testing confirmed), however the change in mental status made the idea of it causing an infection in her head possible. We couldn't confirm because the shingles was covering the part of the body we would use to do a lumbar puncture.

A person was admitted to the hospital three times in two months for headache, nausea and vomiting. All tests looking for infection in the head were negative each time. We were asked to weigh in on the likelihood this was a chronic infection we simply couldn't detect in the lab. While those infections exist, it was more likely this represented a manifestation of her not-fully diagnosed auto-immune disorder. Steroids, not antibiotics, were more likely to be helpful.

Day #2:

A person who was taking immunosuppressive therapy who now had bacteria in the blood. Initially appeared to be a standard line infection (bacteria grow on an IV or central line), however turned in to a septic thrombophlebitis (blood clot with bacteria in it) with an abscess. Despite being surgically drained, the person continued to have bacteria in the blood. More to come.

Day #3:

A person on chemotherapy with a chronic cough who had his sputum cultured one month ago. It just turned positive for mycobacterium gordonae; contaminant or infection to be treated? I decided contaminant and we did not treat.

Day #4:

A person with two recent hospitalizations for pneumonia who now is found to have growths (vegetations) on one of their heart valves and on a lead of their pacemaker. No detectable bacteria in the blood. I decide to cover with antibiotics and have the pacemaker removed. Also talk to the surgeons about whether they need to operate on the valve, given how big the vegetations are. I don't think it was pneumonia, I think the person is sending bits of clot into their lungs.

Day #5:

No new patients, just followed up on existing ones.

Reading list

One of the wonderful side effects of having lots more free time during the interview season has been all the reading I've done. Besides the usual suspects (news, entertainment, health) online, I got through a decent pile of really great fiction:

Kalila by Rosemary Nixon - the story of a child born ill, told from multiple points of view.

The Rumi Collection edited by Kabir Helminski - collection of sufi poetry, using multiple translators.

Brick Lane by Monica Ali - the story of a muslim woman from a small Bangladeshi village, brought to London to marry.

The Marriage Plot by Jeffrey Eugenides - the story of a girl navigating life during her graduation from Brown.

The Hunger Games Trilogy by Suzanne Collins - ostensibly the story of children forced into battle for sport, but with strong political tones. The Ender's Game for this crop of tweens?

Moloka'i by Alan Brennert - the story of a young girl sent to a leper colony in hawaii at the turn of the century.

The Tiger's Wife by Tea Obreht - technically the story of a woman finding out how her grandfather died, but really a collection of lovely eastern european fairy tales.

Cutting for Stone by Abraham Verghese - the story of twins born in an Ethiopian clinic; their complex family relationships, with the backdrop of the Eritrean unrest.

My Own Country by Abraham Verghese - An indian doctor taking care of AIDS patients in TN.

I would honestly recommend all these books, but I have to say I do love Abraham Verghese. Still on the list to get to next: A Visit from the Good Squad by Jennifer Egan, Tinkers by Paul Harding, and Unaccustomed Earth by Jhumpa Lahiri. If you have any suggestions, I'd love to hear them!