HIV and ID Observations

As August becomes September, ID fellows across the land are becoming increasingly skilled, heading rapidly upwards on that steep learning curve that is the first year of fellowship. With one-sixth of the year already in the books, it’s a wonderful thing to see.

One potential downside to this accumulating knowledge, however, is that they start to become familiar — they would say overly familiar — with the cases that make up the bread and butter of our field. “Another liver abscess? Big deal. I’ll get excited when the abscess is drained, and the cytology shows hooklets of Echinococcus — now that’s a case!”

(No one actually said that. It was a hypothetical paraphrase.)

Which is why in a month or two, they will start to wonder if they have any patients on their service that are case conference-worthy.

But the following guide will act as a reminder that yes, the ID service sees the most interesting cases in the hospital, and there is always something worth presenting at weekly case conference. Let’s take look at the options:

1. The Amazing Case. These are obvious, so I will not belabor it, but typically they involve a rarely seen pathogen that somehow found its way to your hospital or clinic. Example: Just back from safari, a man came to the hospital with fever and headache — and lo, he had trypanosomes swimming around his blood smear. Needless to say, the ID fellow taking care of this man with African trypanosomiasis (a.k.a, “African Sleeping Sickness”) had no trouble selecting it for conference. That one was easy, so let’s move on.
2. The Textbook Case. Every so often a patient has an illness that has not just a few, but every characteristic feature of a specific clinical syndrome — it’s as if they read a medical textbook before going to the doctor. Such cases have tremendous educational value, especially for residents and medical students — but really, who among us couldn’t use a refresher on what makes a case a “classic”? Example: The guy with several weeks of fatigue, anorexia, and low-grade fevers, physical exam with all the peripheral stigmata of endocarditis (Roth’s spots, Osler’s nodes, Janeway lesions — can you keep them straight?), a characteristic heart murmur, and a 1.5 mobile aortic valvular vegetation on the cardiac ECHO. Classic.
3. The Funny Bug, Especially if in a Funny Place Case. Certain unusual microorganisms — funny bugs — can be conference-worthy on their own, especially if they have a great name (Staphylococcus lugdunensis) and/or a strong epidemiologic association (Capnocytophaga canimorsus = dogs, Erysipelothrix rhusiopathiae = lobsters, among other creatures). Now throw that funny bug into a funny (unusual) anatomic site, and bingo, you’ve got your case — even if it’s hardly a common manifestation of this infection. Example: A 31-year-old pregnant woman was admitted with abdominal pain and fever — ultimate diagnosis? Acute endometritis and bacteremia from Pasteurella multocida. Of course.
4. The Now Quite Rare but Previously Very Common Case. Progress in vaccines has made certain conditions that were once standard business now quite unusual. As an example, I can count the number of cases of adult measles I’ve seen on one hand, or more precisely, on one finger. As a result, these cases are virtually always conference worthy, plus they give our more senior clinicians (ahem) a chance to wax eloquently about the bad old days. Examples:  Virtually any vaccine-preventable illness (measles, mumps, Haemophilus influenzae invasive disease, even varicella). Bonus points for a case of rheumatic fever or neurosyphilis — not vaccine-preventable, but you get my drift.
5. The Amazing New or Incredibly Confusing Diagnostic Test Case. Just the other day, a colleague from another hospital emailed me with excitement about a case of malaria. It wasn’t the case that was unusual — returning traveler from Africa, fever, etc. — but the fact that his hospital just got the Binax malaria rapid test, and he got the positive result back almost immediately. He was so excited he even took a picture of the positive test with his phone, sending it along with the email. Other examples: The first time you diagnose PCP with blood beta-glucan. Or a case that makes you struggle through the C. diff testing quagmire. Or one that forces you to interpret the results of an EBV antibody panel. Someone with a dozen different Lyme tests (with one of twelve positive).
6. The “Wow” Image Case. Way back in prehistoric times — meaning during my ID fellowship — one of our responsibilities as an ID fellow was to gather the relevant x-rays on our cases, not only for rounds, but also for case conference. It is no understatement that this was a huge challenge — these films were frequently scattered hither and yon throughout the various hospital buildings, so much so that we suspected that the place labeled “Radiology Film Library” was just a front for the hospital casino. And there seemed to be some hospital rule that all interesting brain CTs/MRIs were kept under the call-room bed of the neurosurgical chief resident. Today we have electronic access to all the images, plus everyone is carrying a camera, so we have this great opportunity to display these during conference. Examples: The initial rash of necrotizing fasciitis. Then the operative findings. The volleyball-sized tubo-ovarian abscess in the pelvis on CT scan, prior to drainage. (“Wow,” everyone will say.) The botfly removal (caution, observe at your own risk). You get the picture (ha).
7. The Public Health Case. Let’s just imagine that someone shows up in your emergency department from Liberia/Sierra Leone/Guinea/Nigeria/Senegal. Never mind that they came in for a sprained ankle, someone is going to bring up the possibility of Ebola — especially when, on further questioning, the ankle person from Western Africa admits that 1) yes, they just visited family at home, and 2) yes, they too are worried about it; wouldn’t you be, especially since there’s a bit of headache/joint pain/fever. Since a sprained ankle and Ebola are hardly mutually exclusive, we’re talking prime conference material as soon as you get the consult — golden! Other examples: Any healthcare worker with tuberculosis. Or a restaurant worker with salmonella. You get the idea.
8. The Management Dilemma Case. Despite our thick textbooks and nearly the entire universe of published papers available instantly on line, there’s a ton we still don’t know. I’ve written about a bunch of these clinical situations (here’s the list), and you can tell from the poll results that there really is no right answer — but that doesn’t stop people from having opinions. Another example:  60-year-old woman, professional cellist, has bronchiectasis and slightly worsening cough; a sputum culture is positive for M. abscessus, resistant (as usual) to all oral agents — she can’t imagine a life without playing the cello, and travels frequently. Should he be treated? If so, with what?
9. The Everyone Else Was Messing Up Until We Came In and Saved the Day Case. All doctors love these EEWMUUWCIASTD cases, and they should never be underestimated as high-value material for case conference. In surgical conferences, they invariably present a patient languishing on the medical wards with abdominal pain, until “we took him to the OR and saved his life.” In ID conference, it takes a different form because we do no procedures. It usually involves some perfectly obvious (to us) historical detail that bingo, cracks a mystery case wide open — e.g., “So we simply asked her where she grew up and went to college, and when she told us Tennessee, we knew it was likely histoplasmosis”; or “They thought it was a simple community-acquired pneumonia, but we found out he had a twenty-pound weight loss, hemoptysis, and a history of an untreated positive PPD”; or “All someone had to do was ask her in Spanish/Vietnamese/Chinese/Haitian Creole what was wrong with her, and she told us”; or “He works as a touring semiprofessional golfer, had just returned from Mexico, and mentioned that he licks his golf balls before each drive for good luck.” These EEWMUUWCIASTD cases are tremendously gratifying — they reinforce the fact that we are the smartest doctors in the hospital, plus they make us feel better about the inverse correlation of intelligence with annual income.

I hope the above examples are a reminder that not all ID consults are decubitus ulcers and ICU fevers.

And if I left out a category, please let me know!