 So we've got two PGY-3s giving great talks today. First, Chris Ricks is going to be telling us about a new presentation of a common retinal scar. And I believe we have sort of a guest there as part of that presentation, so that would be great. And secondly, Lee Ferguson, another PGY-3, is going to be talking to us about managing leaky vessels. So my name's Christopher Ricks, I'm one of the PGY-3s. And I just want to start off my presentation with a quote from one of the great authors, actually an actor playing one of the great authors of all time. Every story ever told can be broken down into three parts, the beginning, the middle, and the twist. Well, teaser there for you. So July 2017, beginning. 39-year-old man presented with blurry vision in the right eye, saying, you know, I hit my head a few days ago, and since then, it's been blurry. He was born in Guatemala, hasn't been back in a few years, passed medical history, says the blurriness is worsening, especially the superior half of the vision. Denies any direct trauma to the eye itself, no previous eye problems. And the injury, you know, he had a little bump on his head, but other than that, didn't lose consciousness, was pretty mild in nature. So we did a social history and review systems. Works with chemicals at work in a biohazard suit since starting that job. He's lost about 10 pounds. It's been about three months, non-intentional. He attributed that to just working in a plastic suit, sweating a lot, working hard. He does say he's had bloody stools for the past three weeks. Denies any shortness of breath, night sweats, fever, chills, pain. Denies any IB drug use, risky sexual behavior, or sick contacts. No recent travel, no family history of cancer, eye problems. Does have a family history of diabetes. So on the exam that day, vision has decreased in the right eye, 2070. On exam, you can see a little bit of the cell in his vitreous, which was concerning. And this dilated exam showed this lesion along the inferior arcade that looked like it had some swelling, possibly an overlying rupture of bruised memory as you see that lesion here. So kind of a different presentation of what we expected when someone coming in with half of their vision lost after a bump to the head. You can see here is a black and white photo kind of helping delineate the margins of that lesion. It's also got an OCT, a few things to point out. You can see a fluid underneath the retina here. And then also these little white spots above the retina, which usually indicates some vitreous cell. So a physical exam was done briefly. And the only thing positive was he had these white plaques in his mucus membranes, which were concerning, other than that pretty normal physical exam. So at this point, you know, a working differential diagnosis. So vascular causes, occlusions, rams, inflammation, sarcoid vascularitis, CSR is a young male, CNVM. Infection was really high on our list because of the unilateral nature of his presentation and the overlying vitreous cells. So that doesn't necessarily indicate it has to be infectious. Malignancy is also higher on our differential based on his weight loss and his body stools. And then we couldn't totally rule out trauma because that was what his chief complaint was. So we asked the, this was concerning enough that we decided to ask the internal medicine department to admit him for us so we could do a really expedited form of workup. So we got a lot of testing HIV, RPR, a lot of the usual UVIS, infectious disease type workups that we do, as well as some imaging. Came back with some interesting positives. HIV was positive, a lot of negatives, but he also had his pancytopenia, some elevated liver enzymes and elevated ESR. And then CNV was positive in the blood, which pushes us farther and farther towards that differential, the infectious disease. I want to point out one thing on our differential. This is something else category. This is kind of rising higher and higher with his presentation. So we got a chest x-ray that turned out to be totally normal. We got an MRI which turned out to be totally not normal. You can see here, this is not something you'd expect to see. This would be considered a quote unquote re-enhancing lesion, which brings to mind a few possibilities that a lot of us remember from our board exam days. So we decided to do a vitreous tap, inject Foscarna, clean the myosin, set a lot of labs out to the University of Washington as well as to our own lab here to try to find out what is this exactly. Interesting things came back. So Toxoplasmosis came back, IgG positive, CMV came back negative, which sometimes we'd expect to see that in an HIV positive patient. Everything else came back negative and a CD4 count came back very, very, very low, 24. Just a quick review on what the diagnostic criteria for AIDS is. There's one we're really paying attention to right here. So a CD4 count of less than 200 or some AIDS defining condition. And there's a whole host of different infectious etiologies that count in that category. So continue to kind of watch them working them up while he's impatient for the next few days. You can see an FA here showing some early leakage and then towards the end some late pooling, helping again to just see how big and extensive this lesion is. So five days later, vision had decreased after our treatment with the tap and inject to 2150. You can see it's actually starting to look a little bit better. It's sort of flattened out. You can see the OCT indicates that some of that fluid's gone away. Not quite as much cell individuals. Six weeks later, vision was improving, 2060. In that eye, still again looking better. Three months later, still more and more improvement. He did have a bit of a hiccup about four months after his presentation, which was two weeks ago. He developed this sub-retinal hemorrhage. Vision had dropped to count fingers at five feet. So a pneumatic displacement of the blood was performed in clinic. Avastin was injected, TPA was injected. Post-op day one, he improved to 2,200. And post-op day seven, just a couple of days ago, was down to 2025. So now the twist. He followed up with ID after his discharge and the notes indicated Mr. B, aka Mr. L, is a 39 year old Hispanic male known to the ID service from his previous inpatient stay at the University of Utah. And he presented using a different name than they had documented. The attending who had seen him said, hey, wait a minute, I know you. I'd seen you back in 2013. He'd had a previous diagnosis of HIV and had been very well controlled, but had been lost to fall up due to social and insurance issues. So he'd used a different name than had any previous medical history throughout his entire two week admission, never once admitting that he'd already been diagnosed and already been treated in the past. The CD4 count when he was last seen was 167. Warren Hart and he was pretty well controlled at that time. So it talks about toxoplasmosis here. You can see these are some of the more typical lesions we see when we think of toxoplasmosis. Think of an old scar with some active inflammation next to it. The lesion we saw looked just like the active inflammation part, no scar, which was a new presentation indicated by the IgG was positive versus IgM was not. So for the treatment of toxoplasmosis, there's a variety of ways we can treat this with immune competent individuals as long as the macula is not involved, it's often okay just to observe this. But if we are going to treat them, we can talk about this classic or triple therapy, which is pyrimethamine, sulfadizing, and then systemic corticosteroids if they're immune competent. It's important to emphasize the immune competent part. In this patient, if you have been treated with steroids without that MRI being done, he has this cyst or abscess in his brain, which would not respond well to steroids as we can all imagine. This triple therapy is often times complicated by numerous side effects. GI dermatologic, we always have to monitor for leukopenia, thrombocytopenia. It's not a benign treatment. So usually if there's not a perfect treatment, there's lots of other options that we can try as well. Some of the other common ones are trimethoprim and sulfa, sulfamephoxazole, plus or minus against systemic steroids. Clindamycin, often added as part of the quadruple therapy to the classic triple therapy. For local infections, we can use clindamycin injected into ritually as well as dexamethasone, but for remember that has no systemic benefit to the patient, just local. Atovicoid, and then one of the newer treatments is this azithromycin and pyrimethamine. It has really good response, although it does have a high recurrence. It's been shown to be a non-inferior treatment. So that's something that is always a good thing to consider. We asked one of our infectious disease colleagues, Dr. Throneberry, to add a little bit to things you need to think about when treating patients with systemic Dr. Plasmosis and immunocompetent and immunocompromised patients. Thanks, Christopher. I'm Kyle Throneberry. I'm one of the first-year ID fellows here. I've been following this guy in clinic, so I'm pretty familiar with him. I appreciate the presentation and the kind of the social aspect. We see a fair amount of these patients. I think the big teaching point for me in this case, where I went to medical school, one of the hospitals we worked at was a county hospital and patients with toxoplasmosis and cephalitis, et cetera, usually get treated with Bactrum at high doses. And if you read the CDC guidelines, that's actually pretty common in low-resource settings. The thing I learned here is actually, I was initially told by the medicine team that the patient couldn't afford the pyromethamine component. But actually, it turns out our hospital will pay for the classic regimen. So this guy doesn't have any funding, but they were happy to pay for six weeks of this. And then up to 30 to 40% of patients who get started on the classic regimen have to go off of it, usually for intolerance reasons. And in his case, he got the full six weeks of kind of the induction acute treatment and was having a lot of nausea and even a little bit of vomiting. And was also just having kind of a lag in his CD4 count coming up, which we were attributing to the bone marrow suppression from the regimen. So he's on Bactrum now as kind of part of the long-term phase. And usually we treat these people for quite a long time because recurrence rates are quite high. And so he'll be on kind of a higher dose of Bactrum probably for at least a year or so. It just depends on how high the CD4 count comes up. Usually you like to see it above a 200 for about half a year. I think that's all I have to add. He's globally, this guy's doing pretty well in our clinic and just kind of dealing with some social issues ongoing, but overall doing well, his CD4 counts come up and he's responded to ART, so. Yeah, yeah, no worries. So if you read either one, the CDC guidelines or if you read into Mandel, just just kind of like all expert opinion, but they do have literature cited. Usually until their CD4 count comes up above 200 for six months, their recommendation is one double strength BID. Yeah, so it's a much higher dose than like say the PGPU prophylaxis dose. So he'll be on a high. I think he's on our guys on one double strength BID right now. And again, thank you for coming. So I realize you don't have years of experience in infectious disease. But for residents consulting services or attendings that are starting consulting services, are there specific tips, anything in particular you like or don't like from consulting services on the phone specifically? It's fine if there's nothing perfect. I just want to make sure that for the residents in particular, we're giving you what you want on the console. No, no, I actually, I feel like, especially of all like the surgical services optimology has a more of a tendency to do really good workups and be thorough and really get in contact with us early on and ask for our input. So I appreciate that a lot. I've had a few patients, not just this guy, but over at Huntsman, especially with, end ophthalmitis and things like that. And I feel like there's good communication and I definitely appreciate that. Yeah, no, no recommendations or anything. Thanks for having me. Oh, go ahead. Using the bathroom in your, I guess, present in a lower resource setting. Yeah. But it costs us not an issue. Is this a sound like you're recommending against your bathroom? So, good question. And I looked into this when there was one of the, I think one of the UVitis fellows or something had an epic message for me about this exact question. So I looked into it a little bit. So pretty much all the resources including CDC recommend the classic three drug regimen. And that's mostly from what I can tell based on experience and kind of the summary of all the data they have. And so usually if you can get the drug or the drugs they recommend using that preferred regimen. And then if paramedamine is not available then usually a lot of resources recommend bathroom alone. But like I was saying here I found out they'll, the hospital will pay for it, which is nice. So. Homology, does data support the classic therapy to decrease your rate of recurrence and... Yeah, there's a few, they're all from Europe but there's a few, there's an Italian study and I think a Spanish study that showed that well for encephalitis for example, bathroom is non-inferior. But that limited amount of patients and I think there's a few ophthalmology papers that one of them I've read. It actually compared a substandard dose of this regimen to bathroom and it was bathroom was non-inferior but of course it was not the typical dose that we use. Thanks everybody. Thank you. Definitely was. I agree. So, unfortunately you have me for about three more minutes. One thing that I failed to point out too when we got those antibodies back you have to always remember someone who's immune system is compromised you can't really trust what those antibodies tell you because they may be positive and they might have these or they just becomes a much less a sensitive and specific test. And then kind of the other component to this gentleman's case was the fact that we had no idea what his past medical issue was because he didn't tell us we didn't have the right identification on him. So why do these patients do this? Usually they're not just trying to trick us for the sake of tricking us there's usually a good reason for it. This gentleman's complicated immigration status, legal concerns. This patient had come in with a disability claim with the disability people at his side. So he'd probably been using his work the name he gave us was probably the name he'd used at work. That meant have caused him to just give us that name initially. Workers comp lack of insurance often times where I was in medical school we had a lot of patients that would come in using the same name in birthday and had, we'd look at their notes and didn't make any sense because there'd be 50 people using that exact same name because I knew that name was insured and was a legal citizen so they could get to healthcare. And then also hiding previous medical issues people sometimes are embarrassed there's certain diagnoses out there that have a strong stigma. I was able to get some papers from Lisa and our Dr. Ordon Amy about the prevalence of people avoiding the diagnosis of HIV avoiding admitting to it because of the stigma that comes along with it. And then just denying the fact that they're sick. Oftentimes patients will say well my viral load is undetectable therefore I'm not HIV positive. So they don't want to endorse that they have this disease because in their mind it wasn't positive. So the other half of this is how can we help these people because these patients still need healthcare and they still need us to take care of them. It's easy to become very angry with them and say we just spent two weeks working up for disease you already knew you had. Why didn't you just tell us? But that doesn't help them and it doesn't really help us either. So during the exam it's important to keep an open mind if the chief complaint and the exam findings don't match that should raise red flags. Working with the social work team they're always available to help us. We need to be careful not to scare them away and accuse them and confront them in a negative way because that could scare them away and then we have a patient in this case who's been HIV positive for many years untreated possibly causing other people to become infected. It's important always to seek to understand why they're doing this. As physicians we need to really emphasize the importance of empathy. There's always a reason people are usually doing it because they think this is going to be the best situation and it's the best they know how. We should always address it with that in mind until we have absolute proof that they are doing something malicious. And then just make sure we continue to provide the best medical care possible. And then Dr. Throneberry mentioned this Ryan White program just briefly. It's a program that started after this boy, Ryan White after a blood transfusion, a blood transplant developed HIV positive and died. So his family helped push for litigation and other legal changes that allowed this fund to be created for patients to get treated for the families of the patients, research for HIV positive individuals but it does require them to follow up regularly. There are certain requirements that they have to maintain to stick with the program. Any other questions or comments? Dr. Throneberry, Dr. Shpore, myself or our social work team?