<i>Annals</i> for Educators - 17 May 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives17 May 2016Annals for Educators - 17 May 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201605170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCandidatus Rickettsia tarasevichiae Infection in Eastern Central China: A Case SeriesSevere fever with thrombocytopenia syndrome (SFTS) is caused by a tick-borne virus and is now endemic in eastern China. This study investigated whether another emerging pathogen, Candidatus Rickettsia tarasevichiae (CRT), might be identified alone or as a co-infection in patients hospitalized with SFTS. Differentiation of CRT from SFTS is important because the former can be treated with antibiotics.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners to generate a differential diagnosis for a patient with fever and thrombocytopenia. How would they approach making a diagnosis?Generate a list of tick-borne illnesses. How do Rocky Mountain spotted fever, human ehrlichiosis and anaplasmosis, and Lyme disease differ?What precautions should patients take to avoid exposure to tick-borne illnesses? What evaluation is appropriate if a patient reports finding a tick on his or her body? Is prophylactic antibiotic treatment ever appropriate?Variability in Pathologists' Interpretations of Individual Breast Biopsy Slides: A Population PerspectiveThis study estimates how variability in pathologists' interpretations of a single biopsy slide affects diagnostic accuracy from the perspective of a U.S. woman aged 50 to 59 years having a breast biopsy. Based on interpretation of a single slide, the likelihood that a diagnosis of atypia or ductal carcinoma in situ would be verified by a reference consensus diagnosis is low.Use this study to:Arrange to review the histology slides of a patient on your service with breast cancer. Ask the pathologist to show slides demonstrating atypia and carcinoma in situ. Discuss how confident (or not) such diagnoses are.Why and what treatment is pursued for ductal carcinoma in situ? What are the gaps in our knowledge regarding the best approach? Use the accompanying editorial to help frame your discussion. Ask an oncologist to discuss this with your team. Should the results of this study alter the decision to pursue certain treatments?Ask your learners how they would discuss the potential for uncertainty in the diagnosis of a cancerous lesion. How might your learners help a patient deal with such uncertainty? Are they themselves comfortable dealing with it?Video LearningThe Consult Guys: An MI, a Stent, Bleeding, and Surgery! What Do I Do?In this episode of the consultative medicine talk show, Howard and Geno (The Consult Guys) work their way through a tough one: a recently placed coronary stent, and the need for surgery to remove a gastrointestinal cancer.Use this feature to:Watch the episode with your learners.Review the pharmacologic treatment requirements following the placement of bare-metal and drug-eluting coronary stents. Which drugs are needed, and for how long? Ask an invasive cardiologist to discuss how the type of stent is chosen for each patient.Ask a surgical colleague to discuss how s/he approaches the use of antiplatelet agents in patients who require elective surgery. For how long does s/he prefer such agents be held before surgery?Log on and answer the multiple-choice question to earn CME for yourself!Journal ClubUpdate in Hospital Medicine: Evidence Published in 2015This paper concisely summarizes the findings of 9 key papers in hospital medicine published in 2015. Studies addressed delirium, end-of-life care, treatment of pneumonia, and more.Use this review to:Assign members of your team to read the summary and the paper to which it refers before your next team rounds.Concisely present the key teaching points to each other and then discuss if and how they might alter your practice.Humanism and ProfessionalismOn Being a Doctor: The Firearm for Protection? A Risky BetDr. Wallace describes his debate over whether to purchase a gun for personal protection after a death threat.Use this essay to:Listen to an audio recording of the essay, read by Michael LaCombe, MD.Ask your learners if they have ever felt physically threated by a patient. Do they worry they might become a victim of violence at the hands of one of their patients?How should they handle such a threat? Many professions involve putting oneself at risk. What risks do we take as physicians?Is whether one buys a gun a medical question? Why or why not? Should our choice be influenced in any way by our roles as physicians?MKSAP 17 QuestionA 19-year-old woman is hospitalized for a 3-day history of fever. She has removed several embedded ticks from her skin in the last month. One day before admission, she noted onset of a bilateral temporal headache. On the day of admission, she noted neck stiffness, photophobia, and a new skin eruption.On physical examination, temperature is 39.4 °C (102.9 °F), blood pressure is 130/58 mm Hg, pulse rate is 115/min, and respiration rate is 24/min. She is ill-appearing and resists passive flexion of the neck. Findings on neurologic examination are normal.A typical representation of the skin rash on the trunk and extremities, including the palms and soles of her feet, is shown.Laboratory studiesLeukocyte count14,900/µL (14.9 × 109/L)Platelet count36,000/µL (36 × 109/L)Alanine aminotransferase95 U/LAspartate aminotransferase116 U/LCerebrospinal fluid (CSF) leukocyte count173 (173 × 106/L) (45% polymorphonucleocytes, 52% lymphocytes, 3% eosinophils)CSF Gram stainNegative for organismsUrine pregnancy testNegativeDexamethasone, ceftriaxone, vancomycin, and doxycycline are initiated. Within 48 hours, her fever has resolved, and her platelet count has normalized. Laboratory tests sent at admission reveal no growth on CSF bacterial cultures, and results on serologic testing for Rocky Mountain spotted fever are negative.Which of the following is the most likely diagnosis?A. EnterovirusB. Heartland virusC. Lyme diseaseD. Rocky Mountain spotted feverCorrect AnswerD. Rocky Mountain spotted feverEducational ObjectiveDiagnose Rocky Mountain spotted fever.CritiqueThe most likely diagnosis for this patient, who presents with fever, lymphocytic meningitis, and petechial rash following tick exposure, is Rocky Mountain spotted fever (RMSF). Headache is common in RMSF, and meningoencephalitis is seen in as many as 20% of cases. A rash is present in 85% to 90% of cases of RMSF, although the onset of skin findings may be delayed several days after the initial fever. Early on, the rash is often macular and localized to the wrists and ankles. Over time, this evolves to a diffuse petechial eruption, usually sparing the face. Involvement of palms and soles is characteristic of RMSF, although it is not universal. The low platelet counts and elevated liver enzyme levels also suggest RMSF. Finally, the rapid clinical response to doxycycline is characteristic of RMSF and would make viral entities less likely. The negativity for RMSF antibodies should not discount this diagnosis. During the acute presentation, antibodies to Rickettsia rickettsii are often undetectable because of insufficient time to mount a serologic response to the infection. Testing a convalescent serum specimen obtained more than 14 days after symptom onset allows for retrospective confirmation of RMSF infection. Skin biopsy frequently reveals evidence of vasculitis, and the diagnosis may be confirmed by immunohistochemistry; however, this test is not widely available. A clinically compelling presentation for RMSF should prompt initiation of doxycycline treatment, and this should be continued despite the absence of detectable antibodies.Rash caused by enterovirus is distinguishable from RMSF because it appears morbilliform rather than petechial. Hematologic abnormalities are uncommon with enterovirus infection.Heartland virus is a newly identified phlebovirus transmitted by the same tick that causes ehrlichiosis. Although this infection is associated with thrombocytopenia and elevated liver enzyme levels, it can be distinguished from RMSF by lack of a rash or response to doxycycline treatment.Lyme disease can cause neurologic manifestations, including meningitis, but is associated with erythema migrans rather than a petechial rash.West Nile virus causes neuroinvasive disease in less than 1% of infected patients. It may be associated with a nonspecific rash; however, symptoms would not improve with doxycycline.Key PointFollowing a tick bite, symptoms of fever, petechial rash, and lymphocytic meningitis suggest Rocky Mountain spotted fever and should be treated with doxycycline.BibliographyLin L, Decker CF. Rocky Mountain spotted fever. Dis Mon. 2012 Jun;58(6):361-9.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 May 2016Volume 164, Issue 10Page: ED10KeywordsDoxycyclineEnterovirusFeversLyme diseaseMeningitisRashesRocky Mountain spotted feverStent implantationSurgeryTicks ePublished: 17 May 2016 Issue Published: 17 May 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...