SLLk uesnons

8onald Crossman Mu lCC

rofessor of Medlclne
unlverslLy of 1oronLo


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