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| Fwd: PPIs, Reflux, and Asthma/Case: Headache, Fever, and Rash/Myocar |
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| THIS WEEK'S TEACHING TOPICS |  | | | | | | | | |
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TEACHING TOPIC
1. Proton-Pump Inhibitors, Reflux, and Asthma
ORIGINAL ARTICLE, Efficacy of Esomeprazole for Treatment of Poorly Controlled Asthma, The American Lung Association Asthma Clinical Research Centers, Abstract | Full Text | PDF | PPT Slide Set
EDITORIAL, Silent Acid Reflux and Asthma Control, K. Asano and H. Suzuki, Extract | Full Text | PDF
In this controlled trial, researchers followed 412 patients with inadequately controlled asthma who were randomized to receive either 40 mg of esomeprazole twice a day or placebo. Patients were followed for six months during which they kept daily asthma diaries, answered questionnaires, and underwent spirometry. The primary outcome was the rate of episodes of poor asthma control, as assessed on the basis of entries in asthma diaries. The researchers observed no benefit of proton-pump inhibitors in improving asthma control in patients who have minimal or no symptoms of gastroesophageal reflux.
Clinical Pearls
 Gastroesphageal Reflux and Asthma
There is a high prevalence of asymptomatic gastroesophageal reflux among patients with asthma. Esophageal pH-monitoring studies have shown that 32 to 84% of persons with asthma have abnormal acid reflux. About half of those patients with asthma who have reflux have no symptoms. Symptoms of asthma — cough and chest discomfort — may overlap with those of gastroesophageal reflux, making it difficult to distinguish between the two.
Table 3. Episodes of Poor Asthma Control and Component Events.
Pathophysiology of Reflux and Asthma
The causal relationship between asthma and gastroesophageal reflux is complex. Acid reflux causes bronchoconstriction through microaspiration into the airways, as well as through reflex-mediated effects of acid on the esophagus or upper airway. Asthma-related bronchoconstriction can induce acid reflux. Descent of the diaphragm with hyperinflation increases the pressure gradient between the abdomen and thorax and may cause the barrier function of the lower esophageal sphincter to diminish. Drugs used to control asthma, including beta-agonists and methyxanthine bronchodilators, may decrease the tone of the lower esophageal sphincter.
| Morning Report Question | | Q: |  |
What are the advantages and limitations of ambulatory 24-hour esophageal monitoring? | | A: | |
Ambulatory 24-hour esophageal pH monitoring has been considered the reference standard for the diagnosis of gastroesophageal reflux. Acid reflux can be diagnosed when distal esophageal pH is less than 4 for at least 5% of the total study time; the diagnostic definition correlates well with endoscopically diagnosed erosive esophagitis. However, this method does not evaluate the volume and proximal extent of reflux, factors that may be important for the development of extraesophageal symptoms. Dual-probe esophageal pH monitoring can be more sensitive. Patients with upper airway symptoms who had acid reflux detected at both the proximal and distal probe had a significantly higher incidence of nocturnal cough than those in whom acid reflex was detected only at the distal probe.
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TEACHING TOPIC
2. Case: Man with Fever, Headache, Rash, and Vomiting
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL, Case 11-2009: A 47-Year-Old Man with Fever, Headache, Rash, and Vomiting, S.K. Bell and E.S. Rosenberg, Extract | Full Text | PDF | PPT Slide Set
A 47-year-old man was admitted to the hospital because of fever, headache, rash, and vomiting. The patient had been well until 8 days earlier, when pleuritic chest pain developed, along with a maculopapular rash on his torso. He had fevers of up to 39.1°C, chills, diaphoresis, headache, sore throat, productive cough, swollen lymph nodes, and diffuse myalgias and arthralgias. The patient had had syphilis at the age of 18 years and a negative HIV test 6 months prior to this admission. What is the differential diagnosis?
Clinical Pearls
Secondary Syphilis
Meningeal involvement is common early in secondary syphilis, and fever, pharyngitis, headache, anorexia, lymphadenopathy, and macular or maculopapular rash over the trunk and extremities can occur. The rash, like that of Rocky Mountain Spotted fever, characteristically involves the palms and the soles.
Acute HIV Infection
Signs and symptoms of acute HIV infection include fever, headache, pharyngitis, nausea and vomiting, anorexia, myalgia and arthralgia, diaphoresis, oral or genital ulcers, and lymphadenopathy. Aseptic meningitis has been reported in 24% of cases of acute HIV infection, and myopericarditis has also been described. Laboratory findings may include thrombocytopenia, leukopenia, lymphopenia, and transaminitis. Acute HIV-1 infection is characterized by a negative or weakly positive enzyme-linked immunosorbent assay (ELISA) for antibodies to HIV, a negative or indeterminate Western blot analysis for HIV-1, and high-level viremia detected by means of nucleic acid testing.
| Morning Report Questions | | Q: | |
What is the most common cause of aseptic meningitis? | | A: | |
Enterovirus is the most common cause of aseptic meningitis, especially during the summer, although up to 10% of cases of aseptic meningitis may be attributable to enterovirus during other seasons.
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If a patient's serum for EBV-specific antibodies and CMV-specific antibodies tested negative for IgM and positive for IgG antibodies to both the viral capsid antigens, what would this mean? | | A: | |
These results would indicate previous, but not acute, EBV and CMV infections.
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TEACHING TOPIC
3. Myocarditis
REVIEW ARTICLE, Medical Progress: Myocarditis, L.T. Cooper, Jr., Extract | Full Text | PDF | PPT Slide Set
Myocarditis may present with a wide range of symptoms, ranging from mild dyspnea or chest pain that resolves without specific therapy to cardiogenic shock and death. Dilated cardiomyopathy with chronic heart failure is the major long-term sequela of myocarditis. Most often, myocarditis results from common viral infections; less commonly, myocarditis may result from other pathogens, toxic or hypersensitivity drug reactions, giant-cell myocarditis, or sarcoidosis.
Cardiac MRI is increasingly used as a diagnostic test in suspected acute myocarditis, and may be used to localize sites for endomyocardial biopsy.
Table 1. Clinical Scenarios for the Diagnosis of Myocarditis.
Clinical Pearls
Biomarkers and Myocarditis
Biomarkers of cardiac injury are elevated in a minority of patients with acute myocarditis but, if present, may help confirm the diagnosis. Troponin I has high specificity (89%) but limited sensitivity (34%) in the diagnosis of myocarditis. Clinical and experimental data suggest that increased levels of cardiac troponin I are more common than increased levels of creatinine kinase MB in acute myocarditis.
Causes of Myocarditis
Viral and postviral myocarditis remain the major causes of acute and chronic dilated cardiomyopathy; viruses associated with myocarditis include coxsackievirus B, adenovirus, parvovirus B19, Epstein–Barr virus, cytomegalovirus, and human herpesvirus 6. Other infectious causes of myocarditis include Borrelia burgdorferi (Lyme disease), with or without coinfection of ehrlichia or babesia, and Trypanosoma cruzi infection. Numerous medications including some anticonvulsants, antibiotics, and antipsychotics, have been implicated in hypersensitivity myocarditis. Eosinophilic myocarditis may occur in association with Churg–Strauss syndrome, Löffler's endomyocardial fibrosis, cancer, parasitic, helminthic, or protozoal infections.
Figure 3. Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Heart of a 24-Year-Old Man with Acute Myocarditis.
| Morning Report Questions | | Q: | |
How helpful is an EKG in diagnosing myocarditis and what kinds of EKG changes might you see in a patient with myocarditis? | | A: | |
The sensitivity of the electrocardiogram for myocarditis is low (47%). In a patient with acute myocarditis, the electrocardiogram may show sinus tachycardia with nonspecific ST-segment and T-wave abnormalities. Occasionally, the changes on electrocardiography are suggestive of an acute myocardial infarction and may include ST-segment elevation, ST-segment depression, and pathologic Q waves. Pericarditis not infrequently accompanies myocarditis clinically and is often manifested in pericarditis-like changes seen on electrocardiography.
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When should endomyocardial biopsy be performed? | | A: | |
Endomyocardial biopsy should be performed in patients with unexplained, new-onset heart failure of less than 2 weeks' duration in association with a normal-size or dilated left ventricle and hemodynamic compromise, for suspected fulminant myocarditis. Endomyocardial biopsy should also be performed in patients with unexplained, new-onset heart failure of 2 weeks' to 3 months' duration in association with a dilated left ventricle and new ventricular arrhythmias or Mobitz type II or second-degree or third-degree heart block in patients who do not have a response to usual care within 1 to 2 weeks, for suspected giant-cell myocarditis. (Cooper et al., Circulation, 2007.)
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