Elaine Peplow CPC Loyola

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Information about Elaine Peplow CPC Loyola
Science-Technology

Published on December 6, 2008

Author: elpeplow

Source: authorstream.com

CPC : CPC Elaine M. Peplow, MD September 18, 2008 History of Present Illness : History of Present Illness 65 y/o male brought in by daughter b/c she “didn't like the way he looked” and he was “not being himself” Fatigued Skin color darker Shaking chills x 3wks HPI cont : HPI cont Cough: non productive x 1month Increase in abdominal girth Decreased urine output Further issues : Further issues Recently returned from Mexico one day ago Incidentally: Was hospitalized in Mexico after a fall Hurt his R hip Injured his back Family noted he is “off balance” since ¿Qué Pasa en Mexico?? : ¿Qué Pasa en Mexico?? No fractures per patient/patient’s family "elephant legs full of fluid which they removed slowly” Given unknown pills “meds made me worse” EGD showing esophageal and gastric varices Paracentesis- had “bacteria in my belly” Was then discharged from Mexico hospital 1 week prior to admission Review Of Systems : Review Of Systems POSITIVES +SOB +abdominal girth +LE edema +cough +Decreased urine output +dark urine +rigors NEGATIVES -nausea, -vomiting, -fevers, -dysuria -diaphoresis -hematuria -hemoptysis -diarrhea -constipation Past Medical History : Past Medical History Alcoholic cirrhosis (Dx 2003) HTN DM-II Hernia repair x2 (inguinal and abdominal) Hemorrhoid removal Social History : Social History Tob: 1-2ppd x 37 yr ETOH: beer & tequilas “a lot” Quit 2 years ago Drugs: denies Occupation: former musician Family: unknown Lives with wife and 2 daughters in Chicago Home Medications : Home Medications Ursodiol 250 q 8 Spironolactone 75 bid Lasix 20 qam Folic acid Omeprazole 20 Domus del Chirurgo - House of the Surgeon: Genova, Italy Physical Exam : Physical Exam ED vitals: 98.1, 100, 80/50, 18, 95% RA Gen: AAOx3, answers questions appropriately with translation, cachectic HEENT: icteric, no JVD appreciated, no LAD, dry mucous membranes CVS: RRR, RR, nl s1s2, no s3s4, no m/r/g Pulm: decreased breath sounds on the right, no crackles, no wheezes Abd: soft, NT, + ascites, no hsm, no caput medusa Ext: No c/c, bilateral LE edema, +palmer erythema Skin: Scattered spider angiomata Admission Labs : Admission Labs \ 11.6 / 10.5 -------- 112 / 32.5 \ MCV 96.1 L RDW 21.5 H Neutro: 9.7 (92%) Lymphs: 0.3L (3%) Eos: 0 Baso: 0 134 | 99 | 92 / ------------------ 127 4.6 | 18 | 6.8 \ AST:202 (H) ALT:153 (H) Alk Phos:110 Albumin: 2 (L) Tot bili: 34.2 (H) Troponin <0.03--neg x3 PTT: 545.5 (H) PT: 17.5 (H) INR: 1.8 Ammonia=74 Summary: : Summary: Fatigue, non-productive cough, increased abdominal girth Jaundiced Liver cirrhosis Acute Renal Failure Plan: Admit to Gen Med Temple of Asclepius, Pompeii, Italy Thoughts?? : Thoughts?? Hepatorenal Syndrome : Hepatorenal Syndrome Definition: development of acute renal failure secondary to severe liver dysfunction Criteria Chronic liver disease with ascites azotemia/oliguria Tubular function maintainedUrine:plasma osmolarity ratio >1.0Urine:plasma creatinine ratio >30Urine [Na+] <10 mEq/dL Red cell excretion < 50 cells per high power field Protein excretion less than 500 mg/day Lack of improvement with volume replacement Blendis, Laurie; Wong, Florence. The natural history and management of hepatorenal disorders: from pre-ascites to hepatorenal syndrome. Journal of the Royal College of Physicians of London. 2003. Type I vs Type II : Type I vs Type II Type I Rapid decline in GFR Doubling of creatinine to >2.5mg/dL or 50% decrease CrCl to <20mL/min in 2wks Usually arises in cirrhosis PLUS bacterial infection: most common major surgery massive GI hemorrhage Can occur with patients with Type II Survival time less than 2 weeks Type II Occurs over longer time Creatinine 1.5-2.5mg/dL or GFR<40mL/min Develops in advanced phases of cirrhosis Refractory ascites a lack of response to diuretics Survival time less than 6 months Pathophysiology: Pre-Ascites : Pathophysiology: Pre-Ascites Portal HTN present Increased intravascular volume ­CO, ¯PVR NL/¯MAP Normal/increased GFR Phase II: Early ascites : Phase II: Early ascites Increase in portal hypertension occurs Splanchnic vasodilatation (nitric oxide production) Decrease in effective circulating volume and decrease in renal blood flow More Na retention by kidneys Distal CT sodium resorption & Hyperaldosterone state: -->Spironolactone Arroyo, Vicente, Carolos Terra, Wladimiro Jimenez. Kidney Function in Liver Disease. Primer on Kidney Diseases. Chapter 24. 213-218. 2001. Stage III: Refractory Ascites : Stage III: Refractory Ascites Renal reabsorption of Na continues Vasoconstriction in renal circulation Compensation for under filling of the arterial circulation Paracentesis Peripheral vasodilatation Decreases circulating volume TIPS Volume replete Increase Na excretion One Year Survival Type II patients: 70% Type I patients: 20% Further investigation: : Further investigation: Urine Lytes UNa: 71 Ucr: 58 Uurea: 330 Uosm: 326 Fena: 6.5% Feurea: 42% Urine eosinophils: Neg Not hepatorenal syndrome Hepatology Consult : Hepatology Consult US abdomen shows Small nodular liver consistent with cirrhosis masses in right and left lobe concerning for neoplastic process Very mild L hydronephrosis Concern for malignancy Transplant evaluation Nephrology Consult : Nephrology Consult Urine output slowly decreases Records show NORMAL renal function 3 months prior Tubulointerstitial injury vs medication related (NSAID) Needs dialysis Liver Transplant Labs : Liver Transplant Labs RPR: non reactive Folate: >24.0 Vit B12: >2000 Iron: 79 Transferrin: <70 Alpha Antitrypsin: 127 Hepatitis panel: negative ANA: negative Cryoglobulin: negative EBV IgM: negative IgG: 1440 IgM: 168 IgA: 528 Free kappa: 150 Free lambda:120 C3: 34 L (79-152 MG/DL) C4: 12L (16-38 MG/DL) Labs Continued : Labs Continued Pleural LDH 74 Glucose 175 WBC 190 (20% seg, 22% lymph) Other: 48 Non heme cells suspicious for malignancy CX: Pending Transudative Peritoneal WBC 94 (Segs 10%, Lymph 47) Albumin <1 SAAG: >1.1 CX: Pending PET SCAN Slide 27: AT LEAST THREE FOCI OF INCREASED METABOLIC ACTIVITY MEDIALLY IN THE RIGHT MIDDLE AND LOWER LOBES and RIGHT MIDDLE LOBE ALONG THE RIGHT PLEURAL SURFACE DIFFUSE UPTAKE NOTED THROUGHOUT THE ABDOMEN AND SUGGESTIVE OF PERITONEAL CARCINOMATOSIS CT C/A/P : CT C/A/P 0.5 X 1.3 CM NODULE IS PRESENT IN THE LATERAL SEGMENT OF THE RIGHT MIDDLE LOBE. THERE ARE SEVERAL OTHER NODULAR DENSITIES IN THE RIGHT LUNG WHICH ARE MORE ILL-DEFINED THERE IS INFILTRATION OF THE SUBCUTANEOUS TISSUES ALONG THE LEFT CHEST WALL AND ABDOMEN Liver: SMALL, A NODULAR CONTOUR AND ENLARGEMENT OF THE CAUDATE LOBE; IRREGULAR, ILL-DEFINED LOW-DENSITY LESION IN THE RIGHT HEPATIC LOBE WHICH MEASURES APPROXIMATELY 2.3 X 2.8 CM A MASS IN THE LEFT HEPATIC LOBE Pulmonary Consult : Pulmonary Consult Concern about lung nodules Bronchoscopy performed Anatomy- normal Mucous membranes- icteric Mild secretions throughout R and L mainstem bronchi No lesions BAL: lateral segment of RML and superior segment of RML ….in the meantime : ….in the meantime Pt becomes hypothermic & hypotensive Paracentesis performed: has SBP (WBC 2956, 10% seg, 47% lymph) Started on Zosyn Thoughts? : Thoughts? Pathology : Pathology Mohammed Atieh, DO Department of Pathology Pathology : Pathology Blood Culture Pleural fluid Bronchoscopy Summary of Cultures : Summary of Cultures Pleural Fluid: + cryptococcus Sputum: + cryptococcus Blood cultures: + cryptococcus x 4 separate days Peritoneal Fluid: negative Cryptococcus : Cryptococcus Invasive fungal infection increasingly prevalent with increasing numbers of immunocompromised patients. An encapsulated yeast Subclassified into 4 serotypes Serotypes based upon capsular agglutination reactions, types A, B, C, D Serotype A classified as variety grubii Serotypes B + C variety gattii Serotype D variety neoformans Cryptococcal ecology : Cryptococcal ecology Serotype A & D Soil contaminated by bird droppings (esp chickens and pigeons), roosting sites and rotting vegetation Pigeons do not become infected Cryptococcus can be found in pigeon GI tract Outbreaks of disease not associated with pigeon roosting areas Infection via ingestion of contaminated vegetation Serotype B Eucalyptus trees/soil Is it tropical??? : Is it tropical??? Is it tropical??? : Is it tropical??? Vancouver Island, BC, Canada, in 2001 High outbreak of disease in: cats and dogs, horses, llamas, and ferrets from Vancouver Island Porpoises in the water Also a higher number in humans Fyfe M. et al. (2008) Cryptococcus gattii Infections on Vancouver Island, British Columbia, Canada: Emergence of a Tropical Fungus in a Temperate Environment. Canada Communicable Disease Report. 34(06). Climate? : Climate? Temperature Nanaimo Airport, 1948-2000 Cryptococcus lifecycle : Cryptococcus lifecycle Sexual Form Asexual form yeast which reproduces by budding only form associated with human infection Thick capsule visible in India ink The Life Cycle : The Life Cycle Idnurm, Alexander et.al Deciphering the Model Pathogenic Fungus Cryptococcus Neoformans. Nature Reviews Microbiology. Oct 3,2005. c3, 753-764. Filobasidiella neoformans (sexual state of C. neoformans) Infects Humans The capsule : The capsule Glucuronoxylomannan (GXM): major capsular polysaccharide Most important virulence factor Immunosuppressive Slows humoral immunity Antiphagocytic Inhibits the production of proinflammatory cytokines Depletes complement Decreases leukocyte migration Cryptococcal Presentation : Cryptococcal Presentation Meningitis Behavioral changes Fever Seizures Pneumonia-asymptomatic/mild Skin lesions-lack of inflammation Bone lesions Patients at Risk : Patients at Risk Immunosuppressed HIV/AIDS Cirrhotics Immunosuppressive therapy Cirrhosis & Immunosuppression : Cirrhosis & Immunosuppression Malnourishment Complement deficiency Antibody deficiency Impaired chemotaxis Phagocyte dysfunction Portosystemic shunting bypasses Küppfer cells How Bad is Cryptococcus? : How Bad is Cryptococcus? 47 patients diagnosed with crypto (dx 1981-2001) 46% (24/52) - HIV/AIDS, CD4 <200 23% (12/52) - immunosuppressive therapy 21% (11/52) - decompensated cirrhosis 68% of all patients died by day 30 82% liver cirrhosis died within 30 days Jean, S-S, et al. Cryptococcaemia: clinical features and prognostic factors. Oxford Journal of Medicine: April 1, 2002.95:511-518. Percent Survival Days (all patients) 30days Mortality : Mortality Liver cirrhosis is an independent variable Improved survival if tx begins within 48h of initial culture Multivariate analysis of factors predicting 30-day mortality Jean, S-S, et al. Cryptococcaemia: clinical features and prognostic factors. Oxford Journal of Medicine: April 1, 2002.95:511-518. Cryptococcus in cirrhosis : Cryptococcus in cirrhosis Study of 33pts with cirrhosis & crypto Includes HBV, HCV, ETOH cirrhosis Primary manifestation: peritonitis 67% have positive blood cultures Singh,N. Cryptococcus neoformans Infection in Patients With Cirrhosis, Including Liver Transplant Candidates. Medicine. Volume 83(3), May 2004, pp 188-192. A Note about the Fluid : A Note about the Fluid Average WBC 340/mm3 Cells 44% pts lymphocytes or mononuclear cells (51%-81%) 55% pts PMNs Ascitic fluid culture grew avg 6 days (2-9d) 18th or early 19th century set of three ebony handled trocars with silver sheathed cannulae. Used for abdominal paracentesis Treatment for our patient : Treatment for our patient Amphotericin B was given Flucytosine added on day 8 Patient did not respond to tx Died on day 21 of hospital stay Treatment of Cryptococcus : Treatment of Cryptococcus Amphotericin B and flucytosine (divided into four daily doses) given for 2 weeks Combination has better CNS penetration and less nephrotoxic Fluconazole PO (400 mg/day) if pt clinically improved Bennett JE et al. A comparison of amphotericin B alone and combined with flucytosine in the treatment of cryptoccal meningitis. N Engl J Med 1979 Jul 19;301(3):126-31. New/Future Treatments : New/Future Treatments Calcineurin Inhibitors INDEPENDENTLY have shown improved outcomes in SOT recipients Synergistic action with antifungals Inhibit multi drug resistant pumps Increase susceptibility to azole antifungals Slide 60: Idnurm,A et al. Deciphering the Model Pathogenic Fungus Cryptococcus Neoformans. Nature Reviews Microbiology 3, October 2005. 753-764. Cryptococcal Ca2+-calcineurin pathway Growth Virulence Improve Survival : Improve Survival 69 patients Tacrolimus, cyclosporine Antifungal agents (amphotericin B fluconazole) Assessed 90 day survival Odds of survival: receiving CI compared to not receiving CI: 6.1 (95%CI) Interactions of AmB or fluconazole with immunosuppressive agents versus C. neoformans isolates (90 day survival) Kontoyiannis ,D .Calcineurin Inhibitor Agents Interact Synergistically with Antifungal Agents In Vitro against Cryptococcus neoformans Isolates: Correlation with Outcome in Solid Organ Transplant Recipients with Cryptococcosis. Antimicrobial Agents and Chemotherapy, February 2008, p. 735-738, Vol. 52, No. 2 A word about transplants : A word about transplants Cryptococcus infection occurs in the late post transplant, after proph stopped Most are latent infections reactivated Mortality overall is 20-40% in all transplants Singh, N, et al. Cryptococcus neoformans in organ transplant recipients : Impact of calcineurin-inhibitor agents on mortality. The Journal of Infectious Diseases. 2007, vol. 195 (5) 756-764 . Transplants & Cryptococcus : Transplants & Cryptococcus 111 transplant patients with crypto Patients in: US, Canada, Spain, France, India 68% patients developed infection >1 year post tx Singh, N, et al. Cryptococcus neoformans in organ transplant recipients : Impact of calcineurin-inhibitor agents on mortality. The Journal of Infectious Diseases. 2007, vol. 195 (5) 756-764 . Infection & transplants : Infection & transplants Disseminated Infection 61% disseminated 32% pulmonary limited only Sites of Infection 52% CNS 54% pulmonary 8% skin Risk of Dissemination : Risk of Dissemination Highest risk: liver transplants Lowest risk: lung transplants Recipients of calcineurin inhibitors: Less dissemination Less CNS infection (40% less) Less mortality Medications Matter : Medications Matter Mortality 7.9% in pts receiving tacrolimus 20% cyclosporine A 40%: azathioprine or mycophenolate mofetil Of survival Variables in Mortality : Variables in Mortality Doktor Schnabel von Rom (Doctor Beak from Rome), Rome 1656 Special Thanks : Special Thanks Jaime Belmares, MD Terence Demos, MD Azade Yedidag, MD Mohammed Atieh, DO Praveen Nallapareddy, MD The Chiefs: Katie, Rozy, Tom References : References Arroyo, Vicente, Carolos Terra, Wladimiro Jimenez. Kidney Function in Liver Disease. Primer on Kidney Diseases. Chapter 24. 213-218. 2001. Bennett JE et al. A comparison of amphotericin B alone and combined with flucytosine in the treatment of cryptoccal meningitis. N Engl J Med 1979 Jul 19;301(3):126-31. Blendis, Laurie; Wong, Florence. The natural history and management of hepatorenal disorders: from pre-ascites to hepatorenal syndrome. Journal of the Royal College of Physicians of London. 2003. Fyfe M. et al. (2008) Cryptococcus gattii Infections on Vancouver Island, British Columbia, Canada: Emergence of a Tropical Fungus in a Temperate Environment. Canada Communicable Disease Report. 34(06). Idnurm,A et al. Deciphering the Model Pathogenic Fungus Cryptococcus Neoformans. Nature Reviews Microbiology 3, October 2005. 753-764. Jean, S-S, et al. Cryptococcaemia: clinical features and prognostic factors. Oxford Journal of Medicine: April 1, 2002.95:511-518. Kontoyiannis ,D .Calcineurin Inhibitor Agents Interact Synergistically with Antifungal Agents In Vitro against Cryptococcus neoformans Isolates: Correlation with Outcome in Solid Organ Transplant Recipients with Cryptococcosis. Antimicrobial Agents and Chemotherapy, February 2008, p. 735-738, Vol. 52, No. 2 Singh, Nina, et al. Cryptococcus neoformans in Organ Transplant Recipients: impact of Calcineurin-inhibitor Agents on Mortality. The Journal of Infectious Diseases 195(5):756–764. Singh,N. Cryptococcus neoformans Infection in Patients With Cirrhosis, Including Liver Transplant Candidates. Medicine. Volume 83(3), May 2004, pp 188-192.

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