D|sc|osure of otenna| for Con|ct of Interest Facilitators Name: Ronald Grossman MD FRCPC Grants/research support: GSK, Novartis Speakers bureau/honoraria: Bayer Schering Pharma, GSK, Novartis, Merck, Pfizer, Abbott, Takeda, Grifols Consulting fees: Bayer Schering Pharma, GSK, Novartis, Merck, Abbott, Almirall, Takeda Other: Nil Cb[ecnves Cover lnLeresung aspecLs of lung lnfecuons Lxamlne some aspecLs of lung mallgnancles uesnon 1 A 34-year-old woman was referred for assessmenL of neck swelllng. She wenL Lo her famlly physlclan a few weeks ago and was dlagnosed wlLh hyperLenslon. She sLarLed recelvlng lndapamlde. ShorLly Lhereaer, she noLed swelllng on Lhe rlghL slde of her neck and a rash over Lhe anLerlor chesL. She saw her famlly physlclan who noLed swelllng on Lhe rlghL slde of her neck. Pe arranged a chesL radlograph followed by a C1 scan of Lhe neck and chesL. She had a 30 pack-year smoklng hlsLory. She had no oLher medlcal problems. 8esulLs of a physlcal examlnauon were negauve oLher Lhan Lhe neck swelllng. 1he chesL radlograph and represenLauve lmages of Lhe C1 scan of Lhe neck and chesL are shown. SLLk 21, Cuesuon 2 uesnon 1 (cont'd) AL Lhls polnL, whaL would you do? A. SLarL low-molecular-welghL heparln. 8. Arrange early radloLherapy. C. ulsconunue lndapamlde. u. Arrange urgenL chemoLherapy. SLLk 21, Cuesuon 2 kanona|e Cx8: rlghL lung mass C1 scan: 3.0 x 2.3 cm mass ln Lhe posLerlor segmenL of Lhe 8uL and a 2.9 x 2.0 8 hllar lymph node 8 lnLernal [ugular veln reveals Lhrombosls wlLh surroundlng edema ux: non-small cell ca lung wlLh rlghL lnLernal [ugular veln Lhrombosls 8x: LMWP What's Wrong w|th the Cther Answers Larly radlo8x ls lndlcaLed for SvC obsLrucuon noL presenL ln Lhls case no evldence of an lndapamlde allergy so sLopplng 8x won'L change anyLhlng (swelllng and rash relaLed Lo collaLeral blood supply) Cncology consulL ls Ck buL urgenL chemoLherapy ls noL lndlcaLed unul a ussue dlagnosls ls made Iso|ated Interna| Iugu|ar Ve|n 1hrombos|s: k|sk Iactors and Natura| n|story 74 consecuuve pauenLs wlLh lsolaLed l!v1 29.7 had a hlsLory of cancer 18.9 had a hlsLory of prlor uv1 Cf Lhose wlLh serlal lmaglng (n=40), 17.3 had Lhrombus propagauon 2.7 were dlagnosed wlLh L and 10.8 were dlagnosed wlLh mallgnancy durlng a medlan follow- up of 20 monLhs CuLcomes slmllar Lo Lhose seen ln leg uv1 were observed Shelkh MA, eL al. vascular Medlclne 2002, 7: 177-179 uesnon 2 A 22-year-old man comes Lo Lhe Lu wlLh a 3-day hlsLory of cough and hemopLysls. Pe was well unul 3 days ago when he began Lo noL feel well and developed a cough lnlually producuve of yellow spuLum. Pe developed chesL paln wlLh coughlng and deep lnsplrauon. Pe Lhen had fever, chllls, nlghL sweaLs, and nouceable hemopLysls, coughlng up Lo 1 Lsp of brlghL red blood. Pe also complalned of anorexla buL nouced no welghL loss. 1here was no hlsLory of drug abuse, 18, or 18 exposure. Pe had recenLly reLurned home from a vacauon ln 1ampa, llorlda. Pe has a caL aL home buL no oLher peLs. SLLk 21 Cuesuon 17 uesnon 2 (cont'd) Cn physlcal examlnauon, he had a LemperaLure of 36.1C, 8 of 130/60 mm Pg, hearL raLe of 80/mln, and resplraLory raLe of 18/ mln. 1here was no slgnlcanL cervlcal, supraclavlcular, or axlllary lymphadenopaLhy. 1here were enlarged lymph nodes ln boLh lngulnal reglons. 1he chesL was clear, and Lhe resL of Lhe examlnauon ndlngs were normal. LaboraLory sLudles lndlcaLed normal resulLs of a C8C and blood chemlsLrles, buL a lacLaLe dehydrogenase (LuP) level of 1,382 u/L (26.4 kaL/L). 8esulLs of a urlnalysls were normal. A chesL radlograph and C1 scan are shown. SLLk 21 Cuesuon 17 uesnon 2 (cont'd) 1he nexL sLep ln Lhe lnvesugauon of Lhls pauenL should be: A. erform bronchoscopy wlLh bronchoalveolar lavage (8AL). 8. Plv serologlc Lesung. C. needle asplrauon blopsy of a lung leslon. u. 8epeaL Lhe physlcal examlnauon. SLLk 21 Cuesuon 17 kanona|e MosL llkely dlagnosls ls meLasLauc cancer ln a young man, Lesucular cancer ls Lhe mosL common source 8epeaL examlnauon of Lhe LesLes seeklng a mass ls Lhe correcL answer What's Wrong w|th the Cther Answers 8ronchoscopy wlLh 8AL, asplrauon needle blopsy of Lhe lung and Lhorcoscoplc lung blopsy all unnecessary aL Lhls ume Plv lnfecuon very unllkely ln vlew of essenually no rlsk facLors 1esncu|ar Cancer 8,000 new case annually MosL common Lumor ln men 13 - 34 yrs 8lsk facLors: rlor hx of germ cell Lumor +ve famlly hx CrypLorchlsm 1esucular dysgenesls kllnefelLer syndrome 1esncu|ar Cancer Classled as semlnoma or nonsemlnoma nonsemlnoma: Lmbryonal cell carclnoma Chorlocarclnoma (our case) ?olk sac Lumor 1eraLoma MeLasLaslzes hemaLogenously usually responds poorly Lo radlauon and chemo 1esncu|ar Cancer Chorlocarclnoma meLasLaslzes by hemaLogenous rouLes 1he Lesucular prlmary ls oen small or even "burned-ouL" MorLallLy raLe ls hlgh 1he Lumor responds poorly Lo radlauon and chemoLherapy -PCC has a 24-hour half-llfe and ls secreLed by syncyuoLrophoblasL cells wlLhln Lhe Lumor -PCC ls usually markedly elevaLed ln pure chorlocarclnoma SLandard chemoLherapy for Lhls dlsease ls bleomycln, eLoposlde, clsplaun (8L) for 4 cycles uesnon 3 A 33-year-old man has cough and fever for Lhe pasL 2 weeks. Pls sympLoms sLarLed wlLh a nonproducuve cough, followed by a fever. Aer 2 days, azlLhromycln Lherapy was lnluaLed by hls prlmary physlclan wlLhouL change ln Lhe pauenL's sympLoms. 1he pauenL was referred for furLher evaluauon. 1hls pauenL has a hlsLory of hyperLenslon and focal segmenLal glomerulosclerosls wlLh end-sLage renal dlsease for Lhe pasL 10 years. llve years ago, he underwenL a cadaverlc renal LransplanL, buL Lhe gra falled 3 years ago. MalnLenance Lherapy lncludes hemodlalysls admlnlsLered Lhrough a le forearm sLula Lhree umes weekly. 1he medlcauons he Lakes lnclude llslnoprll, meLoprolol, sevelamer, lron, and a muluvlLamln. Pe avldly works ln hls garden, and he also has Lwo caLs. Pe denles any nlghL sweaLs, welghL loss, or chesL paln. Pe ls a nonsmoker. Pls lasL Luberculln skln LesL 1 year ago was nonreacuve. SLLk 21, Cuesuon 29 uesnon 3 (cont'd) Cn physlcal examlnauon, hls LemperaLure ls 37.9C, 8 ls 143/83 mm Pg, hearL raLe ls 98/mln, and resplraLory raLe ls 22/mln. Pls oxygen saLurauons are 93 on room alr. Pls lungs are clear aL Lhe bases, wlLh scauered rhonchl ln Lhe rlghL upper lung zone. 1here ls no adenopaLhy or skln leslons. Pls W8C counL ls 13,200/ L (13.2 10 9 /L), hemaLocrlL concenLrauon ls 33 (0.33), and plaLeleL counL ls 130 10 3 /L (130 10 9 /L). Pls 8un level ls 83 mg/dL (30.33 mmol/L) and creaunlne level ls 6.7 mg/dL (393 mol/L). 8esulLs of hls currenL chesL radlograph are shown, and Lhe resulL of hls chesL radlograph from 1 year ago was normal. Pls spuLum Cram sLaln shows gram-posluve rods LhaL are also weakly acld fasL. SLLk 21, Cuesuon 29 uesnon 3 (cont'd) Whlch ls Lhe besL anumlcroblal agenL for Lhls pauenL? A. 1rlmeLhoprlm/sulfameLhoxazole. 8. lsonlazld, rlfampln, eLhambuLol, and pyrazlnamlde. C. enlclllln. u. vorlconazole SLLk 21, Cuesuon 29 kanona|e auenL has fever, cough and a 8uL lnlLraLe Cram sLaln: lamenLous gram-posluve rods LhaL are weakly acld fasL upon sLalng ux: nocardlosls 8x: 1M-SMx What's Wrong w|th the Cther Answers? 8x wlLh lnP, 8ll, LM8, ?Z lnapproprlaLe ln Lhe absence of proven 18 enlclllln ls used for Acunomyces lnfecuon Slmllar gram sLaln noL weakly acld fasL CbllgaLe anaerobes and do noL grow ln rouune spuLum culLures no evldence of fungal lnfecuon so vorlconazole ls noL lndlcaLed Nocard|os|s nocardla ls a genus of lamenLous gram-posluve, weakly acld fasL, aeroblc bacLerla found ln solls worldwlde lL ls responslble for acuLe or chronlc lnfecuons prlmarlly ln lmmunocompromlsed hosLs, parucularly Lhose wlLh lmpalred cell-medlaLed lmmunlLy relaLed Lo AluS and LransplanL nocardla asLeroldes complex accounLs for approxlmaLely 83 of all nocardlal lnfecuons and mosL pulmonary lnfecuons kad|ograph|c I|nd|ngs |n Nocard|os|s Lung consolldauon nodules and masses leural lnvolvemenL (rare) ChesL wall exLenslon (rare cause of empyema necesslLaus) Conso||danon Nodu|es and Masses uesnon 4 A 30-year-old woman ls seen ln Lhe hosplLal for nonresolvlng pneumonla. She was well unul 17 days ago when she developed sudden-onseL rlghL pleurluc paln. A chesL radlograph was performed and she was LreaLed wlLh moxloxacln for 10 days. WlLhln a few days of sLarung Lhe anublouc, she developed a cough producuve of yellow- brown unged spuLum wlLh no hemopLysls. She had no fever, chllls, or rlgors buL had eplsodes of nlghL sweaLs on Lwo occaslons. She had mlld anorexla wlLh nonquanued welghL loss. SLLk 21, Cuesuon 33 uesnon 4 (cont'd) She was prevlously well wlLh no pasL medlcal hlsLory. She was a nonsmoker, a nondrlnker, denled Lhe use of recreauonal drugs, and was on no medlcauons. She denled any Lradluonal Plv rlsk facLors. She was born ln Lhe hlllpplnes, had worked as a nanny ln 1alwan for 8 years, and moved Lo Canada 8 monLhs prlor Lo belng seen by her physlclan. Per dog had been lll over Lhe pasL monLh wlLh decreased energy, anorexla, and cough. She had no known lnfecuous conLacLs. SLLk 21, Cuesuon 33 uesnon 4 (cont'd) Cn physlcal examlnauon, she was afebrlle wlLh a 8 of 96/34 mm Pg, pulse of 96/mln, resplraLory raLe of 24/mln, and an oxygen saLurauon of 93 on room alr. 1here were decreased breaLh sounds bllaLerally wlLh mld-lnsplraLory crackles over Lhe llngula and le lower lobe. 1he remalnder of Lhe physlcal examlnauon was normal. A chesL radlograph and C1 scan are shown. 8esulLs of her blood work were normal aslde from a hemoglobln level of 11.3 g/dL (113 g/L) and a W8C counL of 16,900/L (16.9 10 9 /L), wlLh a neuLrophll counL of 11,210/L (11.2 10 9 /L). 8ronchoscopy revealed no endobronchlal leslons or excesslve secreuons. 8ronchoalveolar lavage (8AL) uld ls shown. SLLk 21, Cuesuon 33 uesnon 4 (cont'd) WhaL would you now suggesL? A. lLraconazole. 8. lsonlazld, rlfampln, pyrazlnamlde, and eLhambuLol. C. Llnezolld. u. 1rlmeLhoprlm-sulfameLhoxazole. SLLk 21, Cuesuon 33 kanona|e 8AL uld: many yeasL forms mosL conslsLenL wlLh 8lostomyces CulLures conrmed 8lostomyces JetmouuJls 8x of cholce: lLraconazole AmphoLerlcln 8 ls reserved for pauenLs wlLh progresslve or llfe-LhreaLenlng dlsease What's Wrong w|th the Cther Answers? no acld fasL organlsms are seen ln 8AL uld no lndlcauon Lo sLarL anu-18 8x noL a hlgh-rlsk candldaLe for M8SA 8AL uld noL conslsLenL wlLh M8SA no need for llnezolld no Lradluonal Plv rlsk facLors no organlsms suggesuve of loeomocysus no need for 1M-SMx 8|astomycos|s 1hermal dlmorphlc fungus LxlsLs ln warm molsL soll enrlched by organlc maLerlal lnhalauon of mlcroconldla of Lhe mold form of 8 JetmouJls leads Lo lnfecuon ln lnfecLed ussue, converslon Lo Lhe broad-based buddlng yeasL occurs aL 37 C 8|astomycos|s Lndemlc Lo parLs of mldwesLern and souLh-cenLral uS and Canada ConcenLraLed along Lhe Mlsslsslppl and Chlo 8lver baslns lsolaLed lung lnvolvemenL ln 70-73 of cases 8emalnder have dlssemlnaLed dlsease 8|astomycos|s usually has one of Lhree cllnlcal presenLauons: AcuLe pulmonary blasLomycosls Chronlc pulmonary blasLomycosls ulssemlnaLed blasLomycosls Skln lnvolvemenL mosL common - ln 40-80 of Lhose wlLh dlssemlnaLed dlsease 8ony dlsease and gu dlsease presenL ln 10-30 CnS lnfecuon ln less Lhan 3 wlLh dlssemlnaLed dlsease uesnon S When managlng venulaLor-assoclaLed pneumonla (vA), whlch of Lhe followlng pauenL ouLcomes ls seen wlLh quanuLauve resplraLory culLures compared wlLh semlquanuLauve resplraLory culLures? A. Lower morLallLy. 8. ShorLer lCu lengLh of sLay. C. ShorLer ume on Lhe venulaLor. u. Less use of anubloucs. SLLk 21, Cuesuon 46 kanona|e CuanuLauve culLures: reporL no. of Clu/mL SemlquanuLauve culLures: reporL quadranL growLh on blood agar plaung (1+, 2+, eLc.) CuanuLauve culLures esLabllsh Lhresholds Lo help dene lnfecuon vs. colonlzauon WlLh quanuLauve culLures for vA, cllnlcal narrowlng of anubloucs occurs more readlly Cverall decllne ln overall anublouc use What's Wrong w|th the Cther Answers? CuanuLauve culLures can be obLalned elLher lnvaslvely or nonlnvaslvely MeLa-analysls of 3 8C1s (1240 pLs) no eecL of quanuLauve culLures on: MorLallLy 1lme of mechanlcal venulauon LengLh of lCu sLay Shorr AF, et al. Crit Care Med. 2005; 33:46-53 Meta-ana|ys|s: Morta||ty Invas|ve vs. Non-|nvas|ve 1echn|ques Sanchez-nleLo, eL al. 2.42 (0.73,7.84) 13.0 31 8ulz, eL al. 0.71 (0.28,1.77) 19.3 76 lagon, eL al. 0.71 (0.47,1.06) 30.9 413 Sole-vlolan, eL al. 1.08 (0.39,2.98) 16.3 88 Cverall (93 Cl) 0.89 (0.36,1.41) Favors Invasive Approach Favors Non-Invasive Approach Odds Ratio (95% CI) % Weight n Study 0.13 1 7.84 Odds Ratio for Mortality uesnon 6 A 63-year-old woman has a 1-monLh hlsLory of dry cough, nlghL sweaLs, anorexla, and a 30-lb (23-kg) welghL loss. She ls a nonsmoker. She has Lype 2 dlabeLes, dysllpldemla, and hyperLenslon buL had sLopped all medlcauon 6 monLhs earller aer havlng a dlsagreemenL wlLh her physlclan. She dld noL abuse drugs or alcohol, and Lhere was no hlsLory of recenL Lravel. CLher Lhan le basal crackles, resulLs of a physlcal examlnauon were normal. SLLk 21, Cuesuon 63 uesnon 6 (cont'd) CLher Lhan mlld hyponaLremla (serum sodlum level, 132 mLq/L [132 mmol/L]) and hyperglycemla (glucose level, 490 mg/dL [27.7 mmol/L)]), resulLs of laboraLory sLudles were normal. 8esulLs of chesL radlographs and represenLauve C1 lmages are shown. 8ronchoscopy demonsLraLed no endobronchlal leslons, cyLologlc sLudles were negauve, and culLures grew only normal resplraLory ora. uesnon 6 (cont'd) AL Lhls polnL, you would lnluaLe whlch of Lhe followlng lnLervenuons? A. ercuLaneous dralnage wlLh a plgLall caLheLer. 8. Lung resecuon. C. 8road-specLrum anubloucs wlLh anaeroblc coverage. u. 8ronchoscoplc abscess dralnage. SLLk 21, Cuesuon 63 kanona|e Cx8 and C1 demonsLraLe LLL lung abscess Cllnlcal presenLauon and -ve bronchoscopy suggesL pyogenlc lung abscess no evldence of an endobronchlal obsLrucuon SLandard 8x: prolonged course of broad-specLrum anubloucs wlLh anaeroblc coverage What's Wrong w|th the Cther Answers? ercuLaneous dralnage wlLh a plgLall caLheLer ls one opuon buL ls noL necessary or lndlcaLed aL Lhls ume neumonosLomy or cavernosLomy wlLh dlrecL dralnage (Monaldl procedure) ls posslble lf Lhe pleural space ls obllLeraLed Lung resecuon usually reserved for sepuc compllcauons (morLallLy raLe of 11-28) new Lechnlque: endoscoplc dralnage of lung abscess wlLh uoroscoplc guldance of a gulde wlre replaced by a 90-cm plgLall caLheLer used for anublouc LreaLmenL fallures 8acter|o|og|ca| I|nd|ngs for 90 cases of Commun|ty- acqu|red Lung Abscess |n 1a|wan Wang I et a|. C||n Infect D|s. 200S,40:91S-922 2005 by the Infectious Diseases Society of America Clinical Presentations According to Pathogen(s) Isolated Wang ! eL al. Clln lnfecL uls. 2003,40:913-922 ` uesnon 7 A 44-year-old man complalns of fever up Lo 38.9C, mlld cough, and pleurluc chesL paln for several days. Pe has a hlsLory of acuLe myelogenous leukemla LreaLed wlLh a slbllng allogenlc perlpheral blood sLem cell LransplanL 2 years ago. Pe ls noL currenLly belng LreaLed wlLh anufungal prophylaxls. Pe has had gra- vs-hosL dlsease of hls skln, llver, and Cl LracL for several monLhs managed wlLh hlgh-dose corucosLerolds. SLLk 21, Cuesuon 67 uesnon 7 (cont'd) LaboraLory sLudles show a W8C counL of 4,300/L (4.3 10 9 /L) wlLh 61 neuLrophlls, hemaLocrlL concenLrauon of 37 (0.37), and plaLeleL counL of 133 10 3 /L (133 10 9 /L). A chesL radlograph and C1 scan are obLalned. 1he pauenL undergoes bronchoscopy wlLh Lransbronchlal lung blopsy of Lhe rlghL upper lobe leslon.
uesnon 7 (cont'd) Whlch Lherapy would you sLarL? A. vorlconazole. 8. AmphoLerlcln 8 deoxycholaLe. C. 1rlmeLhoprlm-sulfameLhoxazole. u. Caspofungln. SLLk 21 Cuesuon 67 kanona|e Cx8: 8uL cavlLary lnlLraLe C1: 8uL [uxLapleural cavlLary leslon and a posLerlor lnlLraLe 188x: sepLaLe fungal hyphae wlLh acuLe angle branchlng Compauble wlLh lnvaslve asperglllosus 8x of cholce: vorlconazole
What's Wrong w|th the Cther Answers? 8esponse raLe: vorlconazole: 33 AmphoLerlcln 8: 32 Survlval raLe: vorlconazole: 71 AmphoLerlcln 8: 38 up Lo 30 of pLs who fall vorlconazole may respond Lo 2 nd llne use of caspofungln, posaconazole or a llpld formulauon of amphoLerlcln 8 1M-SMx has no role ln Lhe 8x of lnvaslve asperglllosus 1reatment of Asperg|||os|s Cond|non r|mary 1herapy Secondary 1herapy lnvaslve pulmonary asperglllosls vorlconazole (6 mg/kg lv every 12 h for 1 day, followed by 4 mg/kg lv every 12 h, oral dosage ls 200 mg every 12 h) L-AM8 (3-3 mg/kg/day lv), A8LC (3 mg/kg/day lv), caspofungln (70 mg day 1 lv and 30 mg/day lv Lhereaer), mlcafungln (lv 100-130 mg/day), posaconazole (200 mg Clu lnlually, Lhen 400 mg 8lu C aer sLablllzauon), lLraconazole (dosage depends upon formulauon) Chronlc necrouzlng pulmonary asperglllosls (subacuLe lnvaslve pulmonary asperglllosls) Slmllar Lo lnvaslve pulmonary asperglllosls Slmllar Lo lnvaslve pulmonary asperglllosls Aspergllloma no Lherapy or surglcal resecuon lLraconazole or vorlconazole, slmllar Lo lnvaslve pulmonary asperglllosls luSA Culdellnes. Cllnlcal lnfecuous ulseases 2008, 46:327-60 uesnon 8 A 78-year-old man had a 1-week hlsLory of rlghL-slded chesL dlscomforL and cough assoclaLed wlLh scanLy hemopLysls. Pe had no fever, sweaLs, or chllls. A physlcal examlnauon lndlcaLed decreased alr enLry over Lhe rlghL lower chesL posLerlorly buL resulLs were oLherwlse negauve. 8ouune blood work, lncludlng a C8C, was normal. A chesL radlograph lndlcaLed slgnlcanL rlghL-slded abnormallues and a C1 scan conrmed slgnlcanL parenchymal dlsease and a small pleural euslon. SLLk 21. Cuesuon 81 uesnon 8 (cont'd) 8ronchoscopy dld noL reveal any endobronchlal leslons, and a Cram sLaln of spuLum and bronchoalveolar lavage uld samples lndlcaLed Cram-posluve coccl ln clumps, subsequenLly ldenued as meLhlclllln-reslsLanL SLaphylococcus aureus (M8SA). 1he organlsms were suscepuble Lo LeLracycllne, LrlmeLhoprlm-sulfameLhoxazole (1M- SMx), and vancomycln buL reslsLanL Lo cloxaclllln and cllndamycln. uesnon 8 (cont'd) Whlch of Lhe followlng would you lnluaLe aL Lhls ume? A. Levooxacln. 8. vancomycln. C. 1M-SMx. u. Cllndamycln. SLLk 21 Cuesuon 81 kanona|e ux: CA-M8SA pneumonla 8x of cholce: vancomycln CLher approprlaLe cholces would be: Llnezolld 1lgecycllne What's Wrong w|th the Cther Answers? Whlle Lhe organlsm ls suscepuble Lo 1M-SMx ln vlLro, cllnlcal and experlmenLal reporLs show a mlxLure of success and fallure desplLe Lhls ln vlLro suscepublllLy ln vlLro reslsLance precludes Lhe use of cllndamycln lCs generally noL recommended for any 5. ooteos lnfecuon because of Lhe rapld emergence of reslsLance Probability of Survival of Patients with Staphylococcal Pneumonia, With or Without the Panton-Valentine Leukocidin (PVL) Gene Rubinstein E et al. Clin Infect Dis. 2008;46:S378-S385 2008 by the Infectious Diseases Society of America uesnon 9 A 27-year-old Afrlcan lmmlgranL has cough, spuLum producuon, fever, nlghL sweaLs, and a 20-lb (9-kg) welghL loss. Pe ls found Lo have acuve 18 and concomlLanL Plv lnfecuon. Whlch of Lhe followlng sLaLemenLs ls correcL? A. AnureLrovlral Lherapy (A81) should be delayed unul aer Lhe compleuon of anuLuberculous Lherapy. 8. A81 should be lnluaLed concomlLanLly wlLh anuLuberculous Lherapy. C. 1he lmmune reconsuLuuon syndrome wlll occur aL Lhe same raLe, lndependenL of Lhe umlng of Lhe Lwo Lheraples. u. Aer 6 monLhs of lnluauon of anureLrovlral Lherapy, Lhe Cu4 counL wlll be slgnlcanLly hlgher ln pauenLs recelvlng Lhe Lwo Lheraples concurrenLly. SLLk 21 Cuesuon 107 kanona|e ln a large 8C1, lnluauon of anureLrovlral 8x durlng 18 8x ln pauenLs conrmed wlLh boLh lnfecuons, reduced morLallLy by 36 CD4+ Count Death kate]100 erson yr Death kate]100 erson yr
nk p Va|ue All pauenLs 3.4 12.1 .44 0.003 < 200 cells/ mm 3 8.2 13.3 .34 0.04 > 200 cells/mm 3 1.1 7.0 .16 0.02 lnLegraLed 8x Sequenual 8x n Lngl ! Med 2010, 362:697-706 What's Wrong w|th the Cther Answers? lncldence of lmmune-reconsuLuuon evenLs ls slgnlcanLly hlgher ln Lhe lnLegraLed-Lherapy group compared wlLh pauenLs LreaLed consecuuvely Powever, Lhls compllcauon ls rarely faLal and usually can be managed wlLh corucosLerolds Whlle Lhe Cu4 + counL wlll be hlgher ln pauenLs LreaLed concurrenLly aer 12 mos., (because 8x ls sLarLed early) Lhe Cu4 + counL wlll be slmllar aer 6 mos of anureLrovlral 8x lndependenL of when lL ls sLarLed Comblnlng anu-18 and anureLrovlral 8x does noL speed up or delay Lhe lmprovemenL ln Cu4 + counL uesnon 10 A 73-year-old woman ls readmlued Lo Lhe hosplLal for Lhe fourLh ume ln 2 years wlLh profound hyponaLremla. Lach eplsode was preceded by vomlung and mlld dlarrhea and was assoclaLed wlLh confuslon, and each resolved followlng conservauve managemenL wlLh uld resLrlcuon. no speclc cause was ever found. Per prevlous healLh ls excellenL oLher Lhan hyperLenslon, osLeoporosls, and osLeoarLhrlus, for whlch she recelves dlclofenac, mlsoprosLol, eudronaLe, enalaprll, and aLenolol. Per son sLaLes LhaL she has had rlghL ank dlscomforL for Lhe pasL 3 monLhs, durlng whlch she losL 13 Lo 30 lb (6.8-13.6 kg). She was born ln lndla and llved ln norLh Amerlca for more Lhan 20 years. She ls a nonsmoker. SLLk 21 Cuesuon 121 uesnon 10 (cont'd) hyslcal examlnauon ndlngs are compleLely normal excepL for profound confuslon. LaboraLory sLudles lndlcaLe normal resulLs of a C8C and urlnalysls, and Lhe followlng values: serum sodlum of 103 mLq/L (103 mmol/L), poLasslum of 2.3 mLq/L (2.3 mmol/L), chlorlde of 83 mLq/L (83 mmol/L), and blcarbonaLe of 26 mLq/L (26 mmol/L). Serum osmolallLy ls markedly reduced. urlne sodlum level ls 64 mLq/L (64 mmol/L). 8esulLs of a chesL radlograph and C1 scan led Lo a chesL M8l. A bronchoscopy shows no evldence of Lumor or lnfecuon. SLLk 21 Cuesuon 121 uesnon 10 (cont'd) Whlch of Lhe followlng ls Lhe mosL llkely dlagnosls? A. MeLasLauc lung cancer. 8. ulmonary and splnal 18. C. urug-lnduced lnapproprlaLe anudlureuc hormone syndrome. u. PlsLoplasmosls. SLLk 21 Cuesuon 121 kanona|e auenL has SlAuP: PyponaLremla wlLh hypoosmolallLy of Lhe serum 8enal excreuon of sodlum no cllnlcal evldence of uld volume depleuon CsmolallLy of urlne greaLer Lhan Lhe LonlclLy of Lhe plasma normal renal funcuon normal adrenal funcuon uescrlbed wlLh resplraLory dlsorders such as ca lung, pneumonla and 18 M8l and C1: epldural abscess wlLh lnLerverLebral dlsc desLrucuon ulagnosls: ou's dlsease (splnal 18) L|||son D and 8er| 1. N Lng| I Med 2007,3S6:2064-2072 Diagnosis of SIAD Ellison D and Berl T. N Engl J Med 2007;356:2064-2072 Causes of the Syndrome of Inappropriate Antidiuresis (SIAD) Llllson uP, 8erl 1, n Lngl ! Med 2007, 336:2064-72 Causes of SIADn Mk Imag|ng |n Sp|na| 1ubercu|os|s Splnal Luberculosls ls usually a secondary lnfecuon from a prlmary slLe ln Lhe lung or genlLourlnary sysLem Spread Lo Lhe splne ls LhoughL Lo be hemaLogenous ln mosL lnsLances lnfecuon beglns ln Lhe anLerlor aspecL of Lhe verLebral body ad[acenL Lo Lhe dlsk MosL frequenL slLe of splnal Luberculosls ls Lhe Lhoracolumbar [uncuon MoorLhy S. rabhu nk. A!8 2002, 179:979-83.
Mk Imag|ng |n Sp|na| 1ubercu|os|s paradlskal leslon ls ad[acenL Lo Lhe lnLerverLebral dlsk leadlng Lo a narrowlng of Lhe dlsk space dlsk space narrowlng ls caused elLher by desLrucuon of subchondral bone wlLh subsequenL hernlauon of Lhe dlsk lnLo Lhe verLebral body or by dlrecL lnvolvemenL of Lhe dlsk mosL common pauern of splnal Luberculosls MoorLhy S. rabhu nk. A!8 2002, 179:979-83 Mk Imag|ng |n Sp|na| 1ubercu|os|s AnLerlor Lype ls a subperlosLeal leslon under Lhe anLerlor longlLudlnal llgamenL us spreads over muluple verLebral segmenLs, sLrlpplng Lhe perlosLeum and anLerlor longlLudlnal llgamenL from Lhe anLerlor surface of Lhe verLebral bodles erlosLeal sLrlpplng renders Lhe verLebrae avascular and suscepuble Lo lnfecuon 8oLh pressure and lschemla comblne Lo produce anLerlor scalloplng MoorLhy S. rabhu nk. A!8 2002, 179:979-83.
Mk Imag|ng |n Sp|na| 1ubercu|os|s CenLral leslon ls cenLered on Lhe verLebral body 1he dlsk ls noL lnvolved verLebral collapse can occur, produclng a verLebra plana appearance M8 lmaglng shows a slgnal abnormallLy of Lhe verLebral body wlLh preservauon of Lhe dlsk Appearance ls lndlsungulshable from LhaL of lymphoma or meLasLasls MoorLhy S. rabhu nk. A!8 2002, 179:979-83.
Mk Imag|ng |n Sp|na| 1ubercu|os|s araplegla and someumes quadrlplegla are serlous compllcauons of Lhe Luberculous splne seen ln approxlmaLely 10 of pauenLs Coplous epldural pus and granulauon ussue alone or ln comblnauon wlLh verLebral collapse, subluxauon, or dlslocauon produce cord compresslon 8arely, Lhe pus peneLraLes Lhe dura resulung ln severe menlngomyellus MoorLhy S. rabhu nk. A!8 2002, 179:979-83 What's Wrong w|th the Cther Answers? no hlsLory of drug lngesuon assoclaLed wlLh SlAuP (chlorpropamlde, carbamazeplne, cyclophosphamlde, vlncrlsune, amlLrypullne, haloperldol, SS8ls, monoamlne oxldase anudepressanLs) M8l ls noL conslsLenL wlLh meLasLauc ca lung PlsLoplasmosls rarely assoclaLed wlLh SlAuP and ls even more rarely assoclaLed wlLh verLebral desLrucuon and epldural abscess 1nANk CU