1 00:00:09,630 --> 00:00:10,530 Sara Dong: Hey everyone. 2 00:00:10,530 --> 00:00:14,580 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:15,450 --> 00:00:20,160 We use consult questions to dive into ID clinical reasoning, diagnostics and antimicrobial management. 4 00:00:20,310 --> 00:00:22,860 I'm Sara, your host, and a Med-Peds ID fellow. 5 00:00:22,980 --> 00:00:25,049 I'll introduce our co-host today, Dr. 6 00:00:25,110 --> 00:00:29,189 Annie Jacobs, who you may remember from the ID week 2022 episode. 7 00:00:29,490 --> 00:00:35,730 Annie is a third year internal medicine resident at Atrium Health: Carolinas Medical Center in Charlotte, North Carolina. 8 00:00:35,880 --> 00:00:42,570 She recently successfully completed the ID match process and will be starting her ID fellowship at UT Southwestern in July. 9 00:00:43,199 --> 00:00:44,670 Annie Jacobs: Hey, Sara. 10 00:00:45,570 --> 00:00:46,740 Sara Dong: Glad to have you back, Annie. 11 00:00:47,580 --> 00:00:50,250 All right, and our guest discussant today is Dr. 12 00:00:50,250 --> 00:00:51,180 Christopher Polk. 13 00:00:51,720 --> 00:01:02,520 He is an Associate Professor of Medicine and Assistant Specialty Director of Infectious Diseases Research in the Division of ID at Atrium Health, Wake Forest School of Medicine in Charlotte, North Carolina. 14 00:01:02,820 --> 00:01:07,590 His research interest include COVID-19, CRE producing infections, and HIV. 15 00:01:08,320 --> 00:01:09,340 Christopher Polk: Good to be here. 16 00:01:09,825 --> 00:01:21,735 Sara Dong: So before we get to the cases today, we like to call Febrile a cultured podcast and ask if you would be willing to share a little piece of culture that you have enjoyed recently. 17 00:01:21,765 --> 00:01:23,145 What do you guys got for today? 18 00:01:23,235 --> 00:01:32,735 Annie Jacobs: So I have been binging on true crime podcasts lately, and I have discovered one called Disappearances by Sarah Turney. 19 00:01:33,210 --> 00:01:42,900 It takes you through a variety of people that have gone missing throughout history, sometimes with a very clear suspect and sometimes more ambiguous. 20 00:01:43,080 --> 00:01:48,390 And I highly recommend it to anyone that enjoys stoking their anxiety with a little bit of true. 21 00:01:51,300 --> 00:01:59,010 Christopher Polk: So I actually don't listen to podcasts much with one exception, and, and the time I listen 22 00:01:59,835 --> 00:02:10,275 is during my limited hobbies, which are running and hiking and, and so I like to do long runs. 23 00:02:10,335 --> 00:02:15,195 I've done some marathons and, and during that I will listen to febrile. 24 00:02:16,220 --> 00:02:17,090 Sara Dong: Oh, thanks. 25 00:02:17,300 --> 00:02:18,770 Christopher Polk: My favorite podcast. 26 00:02:21,350 --> 00:02:27,829 Sara Dong: Well, we have some, we're doing things a little bit differently today, and not just having one case, but more than one. 27 00:02:28,370 --> 00:02:30,680 Uh, so Annie, I'm gonna throw it over to you. 28 00:02:30,750 --> 00:02:31,350 Annie Jacobs: Perfect. 29 00:02:32,310 --> 00:02:37,230 Our first case is a patient who presented to our urban hospital in North Carolina. 30 00:02:37,710 --> 00:02:46,800 He's a 70 year old man with a medical history of hypertension and gastric cancer status post fresection andning chemotherapy well over 10 years ago. 31 00:02:47,280 --> 00:02:50,940 He presented with one week of progressive cough and shortness of breath. 32 00:02:51,240 --> 00:03:00,525 He tells us that two years ago he had a Covid 19 infection, and since then he's had some dyspnea on exertion, but it's gotten significantly worse over the past one week. 33 00:03:00,885 --> 00:03:05,640 It is to the extent that he's unable to ambulate around his home without feeling significantly short of breath. 34 00:03:06,720 --> 00:03:13,890 His cough started about two weeks ago and it was initially dry though in the past two days, he's been coughing up a small amount of clear sputum. 35 00:03:14,280 --> 00:03:20,190 On further history, he shares that his breathing has been worse when laying down and he has to sleep with the head of his bed elevated. 36 00:03:20,370 --> 00:03:26,690 He denies any other preceding or concomitant symptoms including nausea, diarrhea, rash, or fever. 37 00:03:28,079 --> 00:03:35,220 The patient's only prescribed medication is losartan, though he admits that he is been out of this medication for over a month and has not been taking it. 38 00:03:35,760 --> 00:03:37,350 He lives at home with his wife. 39 00:03:37,410 --> 00:03:40,560 He has two adult sons, both of whom live in the area. 40 00:03:40,890 --> 00:03:45,570 He's originally from Honduras and moved to this country four years ago to be closer to his family. 41 00:03:46,170 --> 00:03:49,410 He previously worked in construction but has not worked for the last 10. 42 00:03:50,400 --> 00:03:53,700 He denies a history of smoking, drinking, or drug use. 43 00:03:53,760 --> 00:03:55,110 There's no pets in the home. 44 00:03:55,350 --> 00:04:00,420 He denies any sick contacts or historical contacts with people known to have tuberculosis. 45 00:04:02,310 --> 00:04:07,710 Upon presentation to the emergency department, he was tachycardic, normotensive, afebrile. 46 00:04:08,040 --> 00:04:12,260 He was saturating 94% on room air with respiratory rate of 16 to 18. 47 00:04:12,660 --> 00:04:27,630 Physical exam documented in the ED notes a prominent JVD to 13 centimeters, crackles in the bilateral lung fields, irregularly irregular heart rate with no notable murmurs or extra heart sounds, and two plus pitting edema in the lower extremities. 48 00:04:28,050 --> 00:04:35,050 He underwent E K G and was noted to be in new onset atrial fibrillation with rapid ventricular response to the 160s. 49 00:04:35,505 --> 00:04:39,795 Chest X-ray in the emergency department showed pulmonary edema and massive cardiomegaly. 50 00:04:40,245 --> 00:04:42,705 He was started on diltiazem for rate control. 51 00:04:42,825 --> 00:04:47,295 He was admitted and shortly after admission was started on a apixaban for anticoagulation. 52 00:04:48,285 --> 00:04:56,505 While admitted, he undergoes diuresis and on hospital day two, he undergoes an echocardiogram as part of routine workup for new onset AFib. 53 00:04:56,925 --> 00:04:59,885 It shows a large circumferential pericardial effusion. 54 00:05:00,645 --> 00:05:01,605 We can pause here Dr. 55 00:05:01,605 --> 00:05:03,765 Polk and can you talk about your differential in this? 56 00:05:04,725 --> 00:05:05,475 Christopher Polk: Sure. 57 00:05:05,685 --> 00:05:17,925 Although before I dive into that, one question would be, were there clues to the presence of his pericardial effusion prior to obtaining that echo? 58 00:05:18,435 --> 00:05:25,905 You know, sometimes hindsight is really 220-200, and many times it's not completely obvious. 59 00:05:26,775 --> 00:05:33,104 But I do wonder for this patient, on exam were their distant heart sounds. 60 00:05:33,614 --> 00:05:36,525 Did he have low voltage onto E K G? 61 00:05:37,034 --> 00:05:42,135 And we are given a chest x-ray that's described as cardiomegaly. 62 00:05:42,885 --> 00:05:53,655 And you know, classically for a pericardial effusion or what is described is a water bottle sign of an enlarged cardiac silhouette. 63 00:05:54,494 --> 00:06:09,195 And so I just wonder about that appearance of cardiomegaly on the chest x-ray and whether there were just some of those subtle clues to the presence of the effusion be before we got the echo. 64 00:06:10,664 --> 00:06:27,675 But since we're talking about differential, the next question really would be, Were there any signs or symptoms of an acute inflammatory syndrome or acute pericarditis, and we're really not given any here. 65 00:06:27,915 --> 00:06:40,125 So in the H P I, you talked about there really wasn't fever or chest pain or ST elevations on the EKG, suggestive of pericarditis. 66 00:06:40,785 --> 00:06:46,095 He does have a cough, but it sounds like it might just be more from his pulmonary edema. 67 00:06:47,550 --> 00:07:07,080 If he did have some of these acute inflammatory symptoms, then I might be more concerned for an infectious etiology, particularly for a pathogenic bacterial infection like Staph aureus, pneumococcus, or other streptococci diseases. 68 00:07:07,440 --> 00:07:10,879 NNeisseria, Legionella, Mycoplasma. 69 00:07:11,835 --> 00:07:26,385 In my experience, patients with those typical bacterial pathogens generally are fairly ill appearing and, and come in sick with if they have acute pericarditis. 70 00:07:27,795 --> 00:07:41,969 In the absence of that, might think about viral pathogens, coxsackievirus, adenovirus, the one we see in adults is usually H I V, uh, which is something to think about. 71 00:07:43,229 --> 00:07:48,870 Fungal pathogens might be on our differential, especially the endemic fungi. 72 00:07:48,870 --> 00:07:52,650 Blastomycosis, Cocci(dioides), histoplasma. 73 00:07:53,789 --> 00:08:12,210 And then of course we can't forget about tb, tuberculosis, and it's really possible for, uh, effusions from TB to really be more indolent with fewer acute inflammatory symptoms, although maybe patients might have weight loss or night sweats. 74 00:08:12,809 --> 00:08:23,130 So thinking through some of the infectious etiologies of a pericardial effusion, I would think through that set of possibilities. 75 00:08:23,549 --> 00:08:32,339 And then I would also think about non-infectious etiologies, especially given his lack of acute inflammatory symptoms. 76 00:08:33,150 --> 00:08:50,220 You know, as ID clinicians, we are often asked to kind of act as a master diagnostician and really consider non-infectious etiologies, and I just often find it particularly satisfying to make a non-infectious diagnosis. 77 00:08:50,640 --> 00:08:53,280 But just sort of thinking through those possibilities here. 78 00:08:54,480 --> 00:08:55,920 You know, what might they be? 79 00:08:55,920 --> 00:09:10,980 Well, he was recently initiated on anticoagulation, so I think we have to think about bleed a little bit, although on this echo he had, there's really no mention of an aortic dissection or leakage into the pericardial sac. 80 00:09:12,450 --> 00:09:33,705 You know, always think about MI, which might have a complication of pericardial effusion at some point, although presumably maybe he had some cardiac enzymes done or was assessed for that given his new onset atrial fibrillation. 81 00:09:34,335 --> 00:09:40,305 You know, we think about uremia in our adult patients as in etiology in this. 82 00:09:40,305 --> 00:09:47,895 Then for this patient, he does have a history of malignancy and malignant effusions might be a consideration. 83 00:09:48,595 --> 00:10:01,365 Although usually malignant effusions would complicate lung or breast cancer, leukemia, lymphoma, probably not as an isolated recurrence of prior gastric cancer. 84 00:10:01,365 --> 00:10:11,925 That would seem to be unusual, but just sort of thinking through that, uh, mixed edema might cause a pericardial effusion, although, if anything with, 85 00:10:13,020 --> 00:10:16,410 new onset atrial fibrillation with rapid ventricular rate. 86 00:10:16,410 --> 00:10:18,090 You might think he's hyperthyroid. 87 00:10:20,070 --> 00:10:25,590 And then always think about connective tissue disorders too in our differential, right? 88 00:10:25,595 --> 00:10:30,150 Lupus, rheumatoid arthritis, granulomatosis with polyangiitis. 89 00:10:30,420 --> 00:10:45,660 Sarcoid, maybe even familiar Mediterranean fever, all of which I would think would have systemic manifestations, uh, rather than an isolated effusion, but just sort of thinking through a full differential would consider those. 90 00:10:45,660 --> 00:10:53,760 And then that sometimes medications or drugs can cause effusions such as hydralazine, but he really doesn't appear to be on those. 91 00:10:53,970 --> 00:10:59,270 So that's a really big differential to both infectious and non-infectious etiologies. 92 00:10:59,640 --> 00:11:04,730 But the truth is, a lot of times these effusions are idiopathic and we don't find a good answer 93 00:11:05,410 --> 00:11:07,755 and maybe that's the answer here too. 94 00:11:08,325 --> 00:11:17,850 So with that differential, Annie, Do you have some more information so that we can maybe narrow it down or focus on where we're going with this case? 95 00:11:18,180 --> 00:11:19,440 Annie Jacobs: Yes, and thank you. 96 00:11:19,440 --> 00:11:20,910 That was very informative. 97 00:11:20,970 --> 00:11:27,210 I do have more information, but I'd actually like to introduce another patient first, if that's okay. 98 00:11:27,930 --> 00:11:29,670 Christopher Polk: Now you're really throwing some curve ball. 99 00:11:31,440 --> 00:11:34,310 Annie Jacobs: This time our patient is in Chogoria, Kenya. 100 00:11:34,670 --> 00:11:42,385 Chogoria is a small town about 140 miles from Nairobi with somewhat limited availability of diagnostics. 101 00:11:42,805 --> 00:11:47,125 Our patient here is a 23 year old man with no known medical history. 102 00:11:47,575 --> 00:11:50,815 He presented to the hospital with shortness of breath of two weeks duration. 103 00:11:51,385 --> 00:11:54,665 He has a slow but progressive onset of his shortness of breath. 104 00:11:55,410 --> 00:12:01,350 At first he noticed it with extended activity, but over the past two to three days, he's been short of breath, even at rest. 105 00:12:01,800 --> 00:12:05,970 He went to another hospital about a week ago and was told that he had pneumonia. 106 00:12:06,209 --> 00:12:08,430 He was prescribed an oral antibiotic. 107 00:12:08,699 --> 00:12:11,730 He isn't sure which one, and he didn't have improvement. 108 00:12:12,569 --> 00:12:18,449 Further history revealed that he's had chest pain and hemoptysis for two weeks leading up to his current presentation. 109 00:12:19,050 --> 00:12:20,370 The chest pain is sharp in nature. 110 00:12:20,865 --> 00:12:25,155 Anterior in location and exacerbated by inspiration and cough. 111 00:12:25,575 --> 00:12:28,545 His cough is productive of white frothy sputum. 112 00:12:28,905 --> 00:12:31,515 He also notes feeling febrile at home with night sweats. 113 00:12:31,545 --> 00:12:34,815 Over the past two weeks though, he is been unable to take his temperature. 114 00:12:35,355 --> 00:12:36,585 He has no other focal symptoms. 115 00:12:37,095 --> 00:12:44,895 His vitals at presentation show sinus tachycardia, 110 to 120 beats per minute with a blood pressure within normal range. 116 00:12:45,255 --> 00:12:47,925 He's febrile to 103.1 Fahrenheit. 117 00:12:48,105 --> 00:12:54,315 He's tachypnic to 24 breaths per minute, but satting well on RA, he's ill appearing in diaphoretic. 118 00:12:54,945 --> 00:12:58,785 Physical exam is significant for the tachycardia and soft heart sounds. 119 00:12:58,845 --> 00:13:00,935 There's no murmurs, rubs, or gallops. 120 00:13:01,415 --> 00:13:05,790 He's using accessory muscles for respiration with subcostal re retractions. 121 00:13:06,089 --> 00:13:08,819 There's no notable rashes and no lower extremity edema. 122 00:13:08,969 --> 00:13:10,930 He has palpable lymphadenopathy. 123 00:13:11,760 --> 00:13:13,290 Mental status was intact. 124 00:13:13,290 --> 00:13:14,610 On the initial assessment. 125 00:13:15,329 --> 00:13:19,800 Labs showed elevated sedimentation rate of 124 millimeters per hour. 126 00:13:20,400 --> 00:13:24,630 His chest x-ray shows blunted costophrenic angles with massive cardiomegaly. 127 00:13:25,170 --> 00:13:29,710 Ekg showed sinus tachycardia with classical electrical alternans. 128 00:13:30,120 --> 00:13:34,979 Point-of-care ultrasound confirms a massive pericardial effusion with RV collapse. 129 00:13:35,479 --> 00:13:38,560 With this initial presentation, what are your initial thoughts, Dr. 130 00:13:38,560 --> 00:13:38,910 Polk? 131 00:13:39,070 --> 00:13:46,210 How is this similar and different than our patient in North Carolina and how does your patient's differential change with this specific history? 132 00:13:47,470 --> 00:13:54,550 Christopher Polk: Yeah, so this patient really had very clear acute onset of inflammatory symptoms. 133 00:13:54,550 --> 00:13:57,370 So he sounds sick, ill appearing. 134 00:13:57,670 --> 00:14:00,190 He had fevers and chest pain and cough. 135 00:14:00,190 --> 00:14:02,110 That's all new and onset. 136 00:14:03,180 --> 00:14:13,560 And so I would really lean towards an infectious etiology here much more clearly than in our first patient, again, especially given his acuity. 137 00:14:13,560 --> 00:14:20,550 So I would favor a pyogenic bacterial infection, maybe tuberculosis or fungal infection. 138 00:14:21,599 --> 00:14:27,359 And of course, given the location, everyone is really thinking TB. 139 00:14:27,930 --> 00:14:43,680 But I think we have to stop and really do due diligence and consider the the full infectious differential and think about staphylococcal disease, pneumococcal disease, meningococcal disease, all of which are certainly quite possible here. 140 00:14:44,790 --> 00:14:51,090 Of note, where Chogoria is in Kenya is not in the meningitis belt. 141 00:14:51,090 --> 00:14:56,579 It's a little south of that, but you know, certainly would remain a consideration. 142 00:14:57,180 --> 00:15:04,079 Uh, histoplasma also can occur in Africa, so might consider that as well. 143 00:15:06,329 --> 00:15:17,579 I also wanna comment briefly on this patient having cardiac tamponade, which I think is interesting and we didn't really discuss so much in the first case, 144 00:15:18,615 --> 00:15:27,584 still was reported to have a large effusion, but is obviously a very important diagnosis to make and assess for. 145 00:15:28,694 --> 00:16:11,760 And you know, in tamponade, maybe more related to the rapidity of fluid accumulation than the size, and maybe we suspected when there's J V D in the presence of hypotension, which the second patient really didn't have described interestingly, we might also suspect that if there's electrical alternans on the ekg, but if you don't have a handy point of care ultrasound to look for tamponade, the other quick bedside test you can do is a pulses paradoxus so here you check the patient's blood pressure doing inspiration and expiration and 146 00:16:12,479 --> 00:16:16,680 systolic blood pressure drops at least 10 millimeters of mercury. 147 00:16:16,979 --> 00:16:30,479 That's a concern and, and I will just briefly comment, the only time I was ever reprimanded as a resident is when I didn't do this, when admitting a patient and the program director came in the next morning and the patient was in tamponade. 148 00:16:30,930 --> 00:16:34,140 So it's a quick, easy bedside test you can do that. 149 00:16:34,140 --> 00:16:40,620 I'll certainly never forget if you don't have that point of care ultrasound. 150 00:16:40,640 --> 00:16:45,420 Um, so are, are we going to find out more about either of these patients, Annie? 151 00:16:45,990 --> 00:16:47,130 Annie Jacobs: Yeah, we can do that. 152 00:16:47,579 --> 00:16:49,290 Let's go back to the United States. 153 00:16:49,650 --> 00:16:57,390 You'll recall our patient is a 70 year old with a history of gastric cancer who came in with shortness of breath and was found to be a new onset AFib. 154 00:16:57,750 --> 00:17:01,980 And on echo, he was noted to have a massive pericardial effusion. 155 00:17:02,520 --> 00:17:05,069 This patient was initially hemodynamically stable. 156 00:17:05,690 --> 00:17:12,315 Recall that we talked about the differential, including malignancy, infection, and hemorrhagic sources of this effusion. 157 00:17:13,185 --> 00:17:15,195 I'll add some basic labs at this point. 158 00:17:15,765 --> 00:17:22,545 His C B C showed a white count of 12,000 with a hemoglobin of 10 and platelets of 400. 159 00:17:22,875 --> 00:17:28,475 His electrolytes were all within normal limits, a Cr of one and normal BUN. 160 00:17:29,385 --> 00:17:32,045 His a s t and a l t were unremarkabe. 161 00:17:32,220 --> 00:17:35,700 He did undergo a CT chest in the emergency department. 162 00:17:36,000 --> 00:17:43,470 The circumferential effusion is again noted, and he had no lesions in the lung parenchyma, cavitary, or otherwise. 163 00:17:43,680 --> 00:17:47,310 He had trace plural, effusions, far too small to consider tapping. 164 00:17:47,970 --> 00:17:52,470 It was actually at this point in the hospital course that infectious diseases was consulted. 165 00:17:52,940 --> 00:17:58,650 As the ID consultant, what would you suggest in terms of diagnostics in this patient at this point in his hospital? 166 00:18:00,315 --> 00:18:05,895 Christopher Polk: Well, you know, as an ID consultant, the first thing we do is go to bedside and take a better history, right? 167 00:18:05,895 --> 00:18:13,845 We really try and tease out all of those crazy details that no one else probably cares much about. 168 00:18:13,850 --> 00:18:25,310 So, you know, thinking back through this, these pa, this patient, some of the other questions I might ask would be related to further history of any TB exposures. 169 00:18:25,310 --> 00:18:31,620 We told, we were told he really didn't have any, but was from, uh, central America. 170 00:18:32,820 --> 00:18:39,030 Were there any experiences with incarceration or homelessness or other risk factors we can tease out? 171 00:18:39,629 --> 00:18:47,970 Uh, we might think about that in the context of risk factors for endemic fungi as well of. 172 00:18:48,975 --> 00:19:01,425 He was here in Charlotte, where we have a little bit of Histoplasma from time to time, but he was from Central America where there's sort of increasing rates of histoplasma. 173 00:19:01,545 --> 00:19:03,014 So we might think about that. 174 00:19:03,014 --> 00:19:07,545 We might ask about family history of rheumatologic illness, which might. 175 00:19:08,340 --> 00:19:14,790 Provide some clues and, and then we would really wanna embark on a further workup. 176 00:19:14,820 --> 00:19:18,780 We really have some basic labs here, which is great. 177 00:19:19,199 --> 00:19:21,639 He probably doesn't have a uremic effusion. 178 00:19:21,639 --> 00:19:22,740 We know that now. 179 00:19:23,820 --> 00:19:26,010 But what about an H I V test? 180 00:19:26,310 --> 00:19:27,330 Annie Jacobs: It was negative. 181 00:19:27,360 --> 00:19:27,960 Christopher Polk: Okay. 182 00:19:28,470 --> 00:19:32,790 And rheumatologic serologies, presumably those might be. 183 00:19:33,675 --> 00:19:34,035 Annie Jacobs: Yep. 184 00:19:34,095 --> 00:19:38,265 They were all sent by the admitting team and they are in lab being processed. 185 00:19:39,015 --> 00:19:39,825 Christopher Polk: Of course. 186 00:19:40,635 --> 00:19:43,215 Um, we do have a CT chest. 187 00:19:43,215 --> 00:19:54,345 You gave us some imaging and it doesn't seem to suggest any malignancy or recurrence of malignancy, which I think is, uh, helpful here. 188 00:19:55,365 --> 00:19:59,115 You would think there would be some other abnormality in the chest. 189 00:19:59,745 --> 00:20:07,335 Uh, to suggest that as there isn't about a third of the cases of pericardial effusion from TB or from malignancy, sorry. 190 00:20:08,895 --> 00:20:15,135 I presume maybe he had blood cultures at some point since we were talking about bacterial pathogens. 191 00:20:15,615 --> 00:20:20,415 Annie Jacobs: Yeah, they were collected in the emergency department, no growth after 24 hours. 192 00:20:20,565 --> 00:20:21,055 Christopher Polk: Okay. 193 00:20:22,485 --> 00:20:30,905 And, and then the other question is, do we send testing for TB or latent tb, such as an interferon gamma release assay. 194 00:20:31,379 --> 00:20:50,700 Right, so an IGRA doesn't diagnose active tb and there's always this question about what do you do if it is it's positive or negative, particularly with patients from a highly endemic area, but it certainly might raise your suspicion if it was, uh, positive. 195 00:20:51,480 --> 00:20:56,070 I'm not sure it would completely exclude the diagnosis if it was negative. 196 00:20:56,610 --> 00:21:11,520 You know, just looking at some case series from tuberculous peritonitis, a positive igra has a sensitivity and specificity of around 85%. 197 00:21:11,520 --> 00:21:16,860 So that's a positive predictive value, about 90% negative predictive value, 70%. 198 00:21:17,490 --> 00:21:30,185 So it might raise your suspicion for tuberculosis, um, if it's positive, but again, Really excluded from the diagnosis, either if it's negative. 199 00:21:32,015 --> 00:21:39,305 Other things we might do really boil down to obtaining fluid or tissue for diagnosis here. 200 00:21:39,305 --> 00:21:39,635 Right? 201 00:21:40,775 --> 00:21:53,730 And pericardial fluid, while helpful is only diagnostic and about 40% of the time pericardial effusion with from tb. 202 00:21:54,180 --> 00:22:03,450 So something to keep in mind and we can't really use lights criteria on pericardial fluid the way we can for pleural effusions. 203 00:22:04,050 --> 00:22:05,940 That's part is not helpful. 204 00:22:06,419 --> 00:22:16,590 But what we can send, obviously our AFB smears and cultures, and then an adenosine deaminase test. 205 00:22:17,670 --> 00:22:21,060 Which maybe is worth talking a little bit about. 206 00:22:21,420 --> 00:22:37,080 In addition to TB pcr, adenosine deaminase is part of purine metabolism that is elevated in TB and given off by lymphocytes. 207 00:22:37,770 --> 00:22:41,910 It's not exclusive to tuberculosis, but is helpful 208 00:22:42,284 --> 00:22:46,754 to make a diagnosis of a ppleurall or pericardial effusion from tb. 209 00:22:47,564 --> 00:22:50,475 So I think it might be really helpful here to send that. 210 00:22:52,245 --> 00:23:07,304 The other gold standard we can think about is doing a pericardial biopsy, and we classically think about this as increasing yield for making a diagnosis of TB from in the pericardial space. 211 00:23:08,235 --> 00:23:14,940 Unfortunately, it's maybe a little less sensitive than we like to think of it as. 212 00:23:14,940 --> 00:23:30,150 So an AFB smear from pericardial fluid, fluid is only about 5% sensitive, culture is about 50%, and a pericardial biopsy does increase your sensitivity, but only to about 65%. 213 00:23:31,080 --> 00:23:54,345 So making the diagnosis here is a little bit of a challenge no matter what modality you use, but you probably do wanna obtain some fluid and try and think through sending some of those tests again, particularly the adenosine deaminase or the TB pcr, which may have a sensitivity of up to 90%. 214 00:23:54,885 --> 00:24:02,595 And then finally, you could also think you about sending a T-SPOT from your fluid, which also is pretty sensitive, but about 90%. 215 00:24:04,560 --> 00:24:12,630 So that's some of the things I would sort of think through in workup of the patient from the us What, what about that patient in Kenya? 216 00:24:13,155 --> 00:24:16,814 Annie Jacobs: Yeah, well, I will pass those recommendations onto the primary team. 217 00:24:17,115 --> 00:24:28,124 But going back to our patient in Kenya, with that massive pericardial effusion, our patient has become hypotensive to seventies over fifties, in tachycardic to the 130s. 218 00:24:28,335 --> 00:24:30,955 He's also become increasingly somnolent. 219 00:24:30,975 --> 00:24:33,044 He's definitely not stable. 220 00:24:34,004 --> 00:24:42,085 The patient undergoes an emergent bedside pericardiocentesis with placement of a temporary dialysis catheter to serve as a drain. 221 00:24:42,705 --> 00:24:47,700 One liter of dark bloody fluid was drained in the first 30 minutes after placement. 222 00:24:48,300 --> 00:24:50,400 The patient's hemodynamics improved. 223 00:24:50,460 --> 00:24:54,900 Soon thereafter, the patient was started on empiric RIPE therapy. 224 00:24:55,665 --> 00:25:07,095 Over the next three days, a total of three and a half liters of fluid was drained from the pericardial drain throughout the hospital course, the patient clinically improved with a complete resolution of that altered mental status. 225 00:25:07,485 --> 00:25:14,235 Gene expert testing of the pericardial fluid did confirm a diagnosis of tuberculosis. 226 00:25:14,955 --> 00:25:15,304 Dr. 227 00:25:15,304 --> 00:25:16,865 Polk, what are your thoughts about this? 228 00:25:17,790 --> 00:25:18,060 Christopher Polk: Yeah. 229 00:25:18,060 --> 00:25:19,770 No one's surprised here, right? 230 00:25:20,010 --> 00:25:25,380 That that's what everyone was kind of thinking a little bit, especially given the location. 231 00:25:26,160 --> 00:25:30,840 That being said, I would go back to, don't jump to conclusions, do the workup. 232 00:25:31,470 --> 00:25:37,740 I, I'd also say that this is a great demonstration of how epidemiology matters, right? 233 00:25:37,740 --> 00:25:50,670 So in case series of pleural effusions from the US and Europe, Then most are either idiopathic or from malignancy with really the minority being from infection. 234 00:25:51,600 --> 00:26:03,030 Alternatively, from South Africa, a case series published on pericardial effusions identified TB as the most common cause. 235 00:26:03,510 --> 00:26:06,540 So epidemiology always matters. 236 00:26:07,395 --> 00:26:08,415 Annie Jacobs: Absolutely. 237 00:26:08,475 --> 00:26:11,205 That was a really satisfying textbook case from Kenya. 238 00:26:11,715 --> 00:26:13,065 But let's jump back to the US. 239 00:26:13,065 --> 00:26:25,965 With our 70 year old, with our pericardial effusion of unknown etiology, the patient did undergo a pericardiocentesis with one liter of bloody fluid removed cultures and a f B were sent. 240 00:26:26,274 --> 00:26:30,655 Notably that TB P C R that you recommended was not sent in this patient. 241 00:26:31,195 --> 00:26:34,135 No organisms were seen on the initial gram stain. 242 00:26:34,584 --> 00:26:45,054 What treatments, if any, are you starting on this patient at this point in the hospital course and at what point did we consider empiric tuberculosis therapy in this patient in the United States? 243 00:26:46,379 --> 00:27:01,035 Christopher Polk: Well, this is interesting because now we're given information that this was really a large hemorrhagic effusion, and when we think through our differential as far as the etiologies, Of pericardial effusions. 244 00:27:01,875 --> 00:27:13,215 There are only a few things that probably give you a large hemorrhagic effusion most likely, and those are bleed, malignancy and tb. 245 00:27:13,305 --> 00:27:16,175 And we already kind of excluded bleed. 246 00:27:17,175 --> 00:27:24,645 And the fact that he really didn't have trauma here or mention of dissection or concern on echo. 247 00:27:25,125 --> 00:27:39,585 So we're down to thinking about cancer or tb and we've already talked about how it would be unusual for gastric cancer to recur just in the pericardium and from the chest imaging we have. 248 00:27:39,585 --> 00:27:49,695 We don't see a suggestion of other chest cavity malignancy that might go with a malignant effusion. 249 00:27:50,445 --> 00:28:03,345 So we're down to thinking about tuberculosis again, and the fact that he did have a prior residence in a country with higher endemicity of tb. 250 00:28:05,505 --> 00:28:13,365 I'd also say we previously talked about sending an interferon gamma release assay here, and I'm guessing that's still not back yet. 251 00:28:13,455 --> 00:28:14,445 Annie Jacobs: Still in lab 252 00:28:15,035 --> 00:28:19,665 Christopher Polk: and, and that ADA is still in lab? 253 00:28:20,415 --> 00:28:21,735 Annie Jacobs: Yep, still in lab. 254 00:28:21,735 --> 00:28:24,485 Christopher Polk: But hopefully it was at least sent unlike the TB PCR. 255 00:28:26,580 --> 00:28:33,300 You know, at my institution, those usually come back within a week or so, and he's relatively clinically stable. 256 00:28:33,330 --> 00:28:38,970 So to your question, as far as empiric therapy, I'm not sure there's a huge rush. 257 00:28:39,870 --> 00:28:58,125 That being said, if he were sick, certainly would consider starting therapy for a TB and regardless, given where it is on our differential, I presume he's in airborne isolation and we're trying to get three sputums for a f b smear at this 258 00:28:58,125 --> 00:28:58,514 point. 259 00:28:58,875 --> 00:29:00,344 Yes, we are working on it. 260 00:29:00,594 --> 00:29:01,074 Mm-hmm. 261 00:29:02,324 --> 00:29:08,084 Annie Jacobs: So our patient did undergo some workup that you asked for earlier in this conversation. 262 00:29:08,534 --> 00:29:16,435 His rheumatologic workup came back with a negative a n a rheumatoid factor in c c p, and complements were within normal. 263 00:29:17,355 --> 00:29:24,735 For oncologic workup, he underwent a total body PET scan without hypermetabolic activity anywhere in his body. 264 00:29:25,425 --> 00:29:31,275 His infectious workup was a covid and respiratory pathogen panel that came back negative. 265 00:29:31,335 --> 00:29:34,005 The H I V that we already mentioned came back negative. 266 00:29:34,425 --> 00:29:36,915 He had a negative A f B sputum smears. 267 00:29:36,975 --> 00:29:43,035 Three were collected, specifically negative blood cultures, but his QuantiFERON did return. 268 00:29:44,170 --> 00:29:50,590 The pleural fluid was sent for analysis and the ADA was elevated at 55 milliliters. 269 00:29:50,680 --> 00:29:53,140 What do we make of diagnosis at this point? 270 00:29:53,530 --> 00:30:03,790 Christopher Polk: So we're back to tuberculosis just in a different location, and of course we're gonna start him on therapy at this point with what we term is ripe. 271 00:30:03,940 --> 00:30:11,560 Rifampin, isoniazid, pyrazinamide, ethambutol with a little pyridoxine thrown in for. 272 00:30:12,750 --> 00:30:19,740 Prevention of toxicity and you know, certainly want to still get those smears. 273 00:30:19,740 --> 00:30:23,909 He'll, he'll need referral to the health department and ongoing treatment. 274 00:30:24,840 --> 00:30:32,610 But just thinking about TB pericardial disease in general, since we have these two cases, it's interesting because it's really rare. 275 00:30:32,639 --> 00:30:55,730 It's less than 5% of cases of TB present this way and unfortunately, Classically, it had a fairly high mortality rate prior to sort of modern, effective therapy, and still we worry about the complication of constrictive pericarditis because in the later stages of pericardial. 276 00:30:57,824 --> 00:31:08,445 Uh, TB disease, the fluid gets reabsorbed, and then there's scarring of the pericardium, granuloma formation, and constrictive heart physiology can occur. 277 00:31:08,865 --> 00:31:10,395 So that's a concern. 278 00:31:10,425 --> 00:31:15,915 Certainly treatment, uh, with ripe is indicated there. 279 00:31:16,304 --> 00:31:23,564 And then sometimes steroids have been given and the, this is maybe a little controversial, and the, the data. 280 00:31:24,300 --> 00:31:28,200 Inconclusive, but they might be helpful early. 281 00:31:28,470 --> 00:31:41,340 Although studies really haven't completely demonstrated definitive benefit in preventing constrictive pericarditis, but it is a concern. 282 00:31:41,670 --> 00:31:51,830 And if there's progression in some patient, they may need surgical pericardiectomy for constructive pericarditis, but two really interesting cases in different locales 283 00:31:52,094 --> 00:31:54,014 leading to the same diagnosis. 284 00:31:55,665 --> 00:32:01,725 Sara Dong: Thank you so much to Annie and Christopher for making this awesome episode spanning two cases across two continents. 285 00:32:01,905 --> 00:32:11,385 Don't forget to check out the website febrilepodcast.com to find the consult notes, which are written complements to the show, with links to references, our library of ID infographics, and a link to our merch store. 286 00:32:11,460 --> 00:32:16,680 Please reach out if you have any questions, suggestions for future shows, or wanna be more involved with Fbri. 287 00:32:16,890 --> 00:32:17,700 Thanks for listening. 288 00:32:17,700 --> 00:32:18,840 Stay safe and I'll see you 289 00:32:19,020 --> 00:32:19,420 next time.