February 25th, 2020

First Week on Service, with One-a-Day ID Learning Units

There is almost always something to be learned from every new patient.

It might be buried somewhere in the history, or the physical, or the lab tests, or the micro, or the imaging — but the odds are excellent that, with enough rumination, you’ll find it.

I can’t remember now who taught me this important fact, or even if it was ever explicitly stated to me. Quite possibly it was just implied — or personified in action — by some really smart, impressive clinical mentor. Someone skilled in finding that nugget of learning in every case.

It might have been my legendary residency program director; or the World’s Greatest Chief Medical Resident (I’m still missing her, sadly); or the brilliant Chief of ID during my fellowship; or the most intuitive ID clinician on the planet.

(FYI, that last guy remains an invaluable resource on tough cases.)

Regardless, these ID Learning Units are out there. And here are seven — one-a-day — from my first week on the inpatient ID consult service:

1. Cystic neutrophilic granulomatous mastitis. You’ll have an “a-ha” moment the first time you see this strange and challenging entity.

2. Consider pulmonary arteriovenous malformations when encountering a brain abscess, especially if there are no other obvious risk factors.

3. Chronic meningitis — must be one of the most difficult diagnoses in all of ID.

4. A convenient cefazolin dosing strategy in hemodialysis — thanks to Dr. Chris Bland, who pointed out this even better study. A real game-changer for inpatient ID consult services everywhere.

5. With cutaneous lesions that may be zoster, PCR is the diagnostic test of choice — much better than both culture (which lacks sensitivity) and direct fluorescent antibody (DFA) testing, which is highly dependent on getting enough cells.

6. You know those patients with a positive syphilis screening test, a positive confirmatory test, but a negative RPR? Well, as we’ve discussed before, they’re quite unlikely to have neurosyphilis.

7.  When scanning your HIV patient’s historical genotypes, if you find Y188L, that eliminates the entire NNRTI class of drugs. It’s also naturally present in all HIV-2 isolates.

2 Responses to “First Week on Service, with One-a-Day ID Learning Units”

  1. Karolin höfer says:

    It is very good information, thank You

  2. John Paul M says:

    Thank you Dr Paul for sharing those vital “pearls” in ID…I think that Corona would run its course and over a period of time ,with more accessibility to testing would prove to have a far less mortality rate compared to what’s projected now.
    Dr John Paul here

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.