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| Fwd: Infection and COPD/Case: Headache, Vision Loss, and Cold Intole |
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From: NEJM Resident E-Bulletin < resebulletin@...> Date: November 26, 2008 6:04:02 PM EST To: glennskow@...Subject: Infection and COPD/Case: Headache, Vision Loss, and Cold Intolerance/Retinal DetachmentReply-To: resebulletin@...
| THIS WEEK'S TEACHING TOPICS |  | | | | | | | | |
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TEACHING TOPIC
1. Infection and COPD
REVIEW ARTICLE, Current Concepts: Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease, S. Sethi and T.F. Murphy, Extract | Full Text | PDF | PPT Slide Set
In the past two decades, the understanding of infection in the pathogenesis and course of chronic obstructive pulmonary disease (COPD) has increased substantially. New molecular, cellular, and immunologic techniques used to study the host–pathogen interaction have been applied in a reexamination of the role of infection in COPD. This review discusses the evidence and issues that explain how infection is the predominant cause of exacerbations and is a likely contributor to the pathogenesis of COPD.
Clinical Pearls
 COPD Exacerbations
Most exacerbations of COPD are caused by viral or bacterial infection. The clinical manifestations of exacerbations result from direct effects of viruses and bacteria from the host response. Air pollution and other environmental conditions that increase airway inflammation or bronchomotor tone probably account for 15 to 20% of exacerbations. Increased respiratory symptoms resulting from coexisting conditions such as congestive heart failure and pulmonary emboli should be clinically ruled out in the evaluation of exacerbations.
Viral Infections and COPD Exacerbations
Viral respiratory tract infections have substantial clinical consequences in COPD, especially in cases of moderate or severe disease. However, caution must be exercised before concluding that the detection of viral nucleic acid in a sputum sample by means of sensitive PCR assays identifies that virus as the cause of a COPD exacerbation, because viral nucleic acid can be detected in up to 15% of sputum samples during stable COPD.
Table 1. Microbial Pathogens in COPD.
| Morning Report Questions | | Q: |  |
What are the most common bacterial pathogens in the lungs of patients with COPD? | | A: | |
The most prevalent bacterial pathogens in COPD are Haemophilus influenza and Pseudomonas aeruginosa. These pathogens enhance mucous secretion, disrupt normal ciliary activity, and cause airway epithelial injury, thereby further impairing mucociliary clearance.
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Is it appropriate to start antibiotics for an acute COPD exacerbation? | | A: | |
Antibiotics are not beneficial for a mild exacerbation but are beneficial in the treatment of moderate and severe COPD exacerbations, especially when purulent sputum is one of the presenting symptoms. Initial antibiotic choice (before any specific infectious agent is identified) should be based on the patient's age, risk factors, FEV1, number of exacerbations per year, recent antibiotic exposure, and presence of cardiac disease. (See table below.) Observational studies have identified advanced age, severe airflow obstruction, recurrent exacerbations, and coexisting cardiac disease as predictive factors for poor clinical outcomes after a COPD exacerbation.
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Figure 4. Algorithm for Antibiotic Treatment in Patients with Acute Exacerbations of COPD.
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TEACHING TOPIC
2. Case: Pituitary Tumor and Skull Abnormalities
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL, Case 37-2008: A 17-Year-Old Boy with a Pituitary Tumor and Skull Abnormalities, E.R. Smith and Others, Extract | Full Text | PDF | PPT Slide Set
A 17-year-old boy presented with headache, progressive vision loss, mood changes, worsening academic performance, fatigue, cold intolerance, and weight gain. Examination revealed bitemporal hemianopia; decreased visual acuity; a positive Hoffmann's sign on the right side; normal strength, sensation, and other reflexes; striae on the trunk; an absence of chest and facial hair; and mild obesity. MRI of the head revealed a cystic-appearing lesion in the sellar and suprasellar region. What is the differential diagnosis?
Table 2. Differential Diagnosis of Sellar Lesions in Children.
Clinical Pearls
Headaches in Adolescents
Headaches are common in this age group, with nearly one third of adolescents reporting weekly headaches. One of the most difficult issues facing pediatricians in the evaluation of children with headache is identifying the approximately 4% of such children who actually have intracranial lesions. Predictors of a mass lesion include sleep-related headache, vomiting, confusion, focal neurologic abnormalities, the absence of typical migrainous visual phenomena, lack of family history of migraines, and the presence of headaches for less than 6 months.
Figure 1. CT and MRI Studies of the Skull Base.
Elevated Prolactin Levels
Elevated prolactin levels may have several causes, including induction by pharmacologic agents (particularly lithium), compression of the infundibulum or pituitary gland (the “stalk effect,” whereby compression of the pituitary gland or stalk interferes with the delivery of dopamine from the hypothalamus to the pituitary), or normal processes (e.g., pregnancy, nursing, and nipple stimulation). However, most of these causes do not lead to prolactin levels above 100 to 200 ng per milliliter; levels of 500 ng per milliliter or higher are usually indicative of a prolactinoma. Tumor size and serum prolactin levels have a direct correlation.
| Morning Report Questions | | Q: | |
What is indicated by bitemporal hemianopia indicate? | | A: | |
Bitemporal hemianopia strongly suggests involvement of the optic chiasm where compression of crossing fibers from nasal retinal fields can cause this visual defect.
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What is Hoffmann's sign? | | A: | |
Hoffmann's sign — also called the digital reflex — consists of flexion of the terminal phalanx of the thumb and of the second and third phalanges of the other fingers followed by extension when one of the middle fingertips is flicked.
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TEACHING TOPIC
3. Primary Retinal Detachment
CLINICAL PRACTICE, Primary Retinal Detachment, D.J. D'Amico, Extract | Full Text | PDF | PPT Slide Set | Audio
A 57-year-old man noted flashing lights in his right eye, followed two days later by a cluster of dark floaters that mildly interfered with his vision. Over the course of the next week, he developed vision loss initially in the nasal visual field of the right eye followed by decreased central acuity. Examination of the fundus with the pupil dilated showed a retinal detachment involving the temporal retina, including the macula, with peripheral retinal tears at the 10:30 and 11:30 positions. How should his case be managed?
Clinical Pearls
Posterior Vitreous Detachment
Although typically an acute event, posterior vitreous detachment is a consequence of lifelong vitreous liquefaction and is highly age-dependent, occurring in less than 10% of persons younger than 60 years of age but in 27% of people in the seventh decade of life and 63% of those in the eighth decade of life; it occurs earlier in people who have myopia. In most cases, patients perceive floaters of various types, including newly mobile normal vitreous structures, occasional vitreous hemorrhage (at times severe), and pigmentary debris, and 22 to 44% of patients see flashing lights.
Figure 1. Primary Rhegmatogenous Retinal Detachment with a Horseshoe Tear.
Treatment for Retinal Detachment
The three principal methods for reattachment of the retina are scleral buckling, vitrectomy, and pneumatic retinopexy. The least invasive and least expensive of the three is pneumatic retinopexy, a procedure performed in the ophthalmologist's office. A small bubble of pure sulfur hexafluoride or perfluoropropane is injected intravitreally. With appropriate positioning of the head, retinal breaks are closed by the bubble, allowing the retinal pigment epithelium to pump to reattach the retina. Gradual dissolution of the bubble from the eye coupled with permanent closure of the break by retinopexy reattaches the retina permanently. This is not a suitable treatment for every retinal detachment, owing to practical limitations in the ability to close breaks by head positioning with an intraocular gas bubble.
| Morning Report Questions | | Q: | |
How quickly should a patient with new symptoms of flashing lights or floaters be evaluated? | | A: | |
Patients with new symptoms of flashing lights or floaters or with loss of central or side vision should be evaluated promptly (ideally, within a few days if flashes or floaters are the only symptoms and within 24 hours if there is any visual loss) to determine whether posterior vitreous detachment, retinal breaks or detachment, or other problems are present.
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What is a pseudophakic eye? | | A: | |
A pseudophakic eye is an eye with an artificial intraocular lens.
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Thu Nov 27, 2008 12:44 am
Glenn Skow <glennskow@...>
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