Professional Documents
Culture Documents
Swami Vivekanand
The Definitive Review of
Medicine for USMLE
Vineet Punia MD
Associate Research Assistant
Department of Neuroradiology
Memorial Sloan-Kettering Cancer Center
New York City, NY, USA
Preparation for USMLE is more of an art form than just labor. It is more about following a certain path, rather than
running all over the field. This axiom gains more credibility especially when you are studying Medicine for USMLE.
I do not know how possible it is to master the field of medicine, but I am sure it is not at all easy. But thankfully,
Medicine in USMLE is not about its vastness or obscure details but more about basics and their application.
As someone who has danced the dance of USMLE, I realized during my times of preparation that there is no
single work in review of medicine that suffices the need of actual exam. One has to refer to so many things and go
through a lot of hassles to make oneself ready for it. So my endeavor of writing this book is to gather all the information
in medicine, required to champion the USMLE, in one book. From my personal USMLE experience and as an author,
I would suggest you to make your fundamentals clear and be adept at their application.
Diagnosing a disease is the most important part in answering any question right in medicine. Within the text,
you will find Diagnosis clinchersthe features of diseases that will help you to nail down the diagnosis, just by
their presence in questions.
If you are eyeing the coveted score of 99, then you need to master the 99ers mentioned between the text. These
are those special points and concepts that help a student score high and mastering them, shall take you closer to
your dream of 99.
I personally have always felt that tabulated form of text is the best way to put across the point most precisely and
effectively and also the information is more palatable. Therefore, any information that could be presented in tabulated
form has been presented in the said form.
Finally, the journey of USMLE is long and may be tiring but remember the only thing that is going to get you
through is regularity, perseverance and your approach towards preparation. So find the way that suits your style of
studying and never follow anyone. I wish you very best of luck in your quest to come up trumps.
Vineet Punia
Acknowledgements
This book would have never seen the light of the day, if it wasnt for the people who supported me and put their
faith in me. The foremost, of course, are my parents whose constant encouragement and care made me sail through
times of self-doubt and low confidence. No words can express the respect, gratitude and feelings I have for them.
I would like to thank Nasib Uncle, who constantly guided me while the book was coming up, and Anil, my
maama, who always has been and will be my source of inspiration and motivation.
I cant acknowledge enough the contribution of Deeksha, my sister, and Bhupender who were my de-stressors
during the time this book was shaping up.
I would also like to thank all my friends, relatives and loved ones because of whose blessings I was able to
achieve my dream of authoring this book.
I would also take an opportunity to apologize to my friends Ankush, Nitin, Satinder, Kunwar, Farooqi, Vivek
and many more whom I couldnt attend properly because of my deep involvement with the book.
The writing of this book has been a very memorable experience both personally and professionally that I will
cherish whole of my life.
In the end, I would also like to thank Shri Jitendar P Vij (Chairman and Managing Director) and Mr Tarun
Duneja (Director-Publishing) of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for the trust they put in me.
My heartiest thanks to everyone.
The Definitive Review of Medicine for USMLE
Vineet Punia
Contents
2. Infectious Diseases------------------------------------------------------------------------------------------ 13
3. Rheumatology ------------------------------------------------------------------------------------------------ 44
5. Nephrology ---------------------------------------------------------------------------------------------------- 77
7. Hematology --------------------------------------------------------------------------------------------------110
8. Gastroenterology -------------------------------------------------------------------------------------------128
9. Endocrinology -----------------------------------------------------------------------------------------------147
Index ------------------------------------------------------------------------------------------------------------213
Chapter
1 Emergency Medicine
Flow chart 1.1: Basic life support (American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Courtesy: American Heart Association [AHA] (http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-19)
vascular disease. Patients with pseudo-PEA usually Preload and afterload changes - Severe hypovolemia,
are younger, have a normal QRS interval, and are more massive pulmonary embolus, sepsis.
likely to respond to epinephrine than patients with Metabolic changes - Hyperkalemia, hypothermia, drug
no aortic pressure. ingestion (tricyclic antidepressant overdose, digitalis
overdose, calcium channel and beta-blockers).
Various causes may be: Post-defibrillation PEA- After prolonged ventricular
Pulmonary - Respiratory arrest: fibrillation and electrical cardioversion.
Mechanical - Cardiac tamponade, massive myocardial
infarction, cardiac rupture, tension pneumothorax, Clinical Features
auto-Positve end expiratory pressure (PEEP) due to Apart from an unresponsive patient, with no peripheral
mucous plugging, bronchoconstriction, inadequate pulses, patient may present with features typical of the
time expiration, severe congestive heart failure (CHF). causative pathology.
Emergency Medicine 3
THERMAL INJURIES each. Lund and Browder Chart is used to calculate BSA in
children. Patchy burns can be estimated by using one
Burns hand's width as an estimate of 1% of BSA burned.
Burns can be thermal burns, chemical burns, and radiation Respiratory system involvement should be assessed by:
burns. Thermal burns can be further classified according X-ray: Helps assess the extent of injury.
to skin depth and percentage of total body area burned. Bronchoscopy: Reveals thermal injury even when
They are most dangerous when associated with damage x-ray is normal.
to respiratory system. Deaths in times of fire occur mostly Carboxyhemoglobin: To assess the extent of CO
due to smoke inhalation and CO inhalation. Burn depth is poisoning.
described as first, second, or third degree.
Treatment
First-degree burns (involve only the epidermis): Tissue
is erythematous, often painful and blanches with The American Burn Association has developed criteria
pressure. Tissue damage is minimal and capillary for burn center admission, which are follows:
refill remains normal. Sunburn is a classic example. Full-thickness (third-degree) burns over 5% BSA
Second-degree burns/partial-thickness burns (involves Partial-thickness (second-degree) burns over 10% BSA
epidermis and portions of the dermis): The burned area Any full-thickness or partial-thickness burn involving
characteristically has blisters and is very painful. critical areas (face, hands, feet, genitals, perineum, skin
Third-degree burns/full-thickness burns (involves over any major joint), as these have significant risk for
epidermis and dermis): These burns are characterized functional and cosmetic problems
by charring of skin or a translucent white color, with Circumferential burns of the thorax or extremities
coagulated vessels visible below. The area is insensate, Significant chemical injury, electrical burns, lightning
but the patient may still complain of pain, which is injury, coexisting major trauma, or presence of
significant preexisting medical conditions
usually a result of surrounding second-degree burns.
Presence of inhalation injury.
Recovery typically presents with extensive scarring.
Severe burns are defined as combined second- and Patients should be immediately intubated who are:
third-degree burns > 20% or third-degree burns >5% of Unconscious or obtunded.
body surface area (BSA). In respiratory distress
Presenting with facial burn, singed nasal hairs, soot
Clinical Features in the airway, and carbonaceous sputum.
Topical antibiotics such as silver sulfadiazine or
During physical examination apart from the visible burns,
mafenide can be applied on burns. Establish intravenous
concentrate on finding any signs of soot in mouth or nose,
access and begin fluid resuscitation. Two large-bore
burnt nose hairs, wheeze, stridor, altered mental status;
peripheral lines should be established. Fluid needs for
which are clues to respiratory system involvement and
burn victims in the acute phase can be calculated using
may portend laryngeal and pulmonary edema. Patient
the Parkland formula, as follows:
with CO exposure and poisoning may appear with altered
mental status, dyspnea, headache, and chest pain. Patient (4 cm3 of crystalloid) (% BSA burn) (body weight in kg)
with extensive burns may go into shock due to various
One half of the calculated fluid requirement is
endogenous substances released in blood. Circumferential
administered in the first 8 hours, and the balance is given
burns may tighten as they heal and cut off circulation, over the next 16 hours. Ringer's lactate is preferred liquid.
leading to limb compromise. Burns can also lead to peptic Foley catheter simplifies monitoring of adequacy of fluid
ulcer and pancreatitis. replenishment by measuring hourly urine output which
'99er'- Most threatening inhalational injury is sub should be maintained at 0.5- 1 cm3/kg/h. Care should be
glottis edema, which can be assessed by fiberoptic taken about pain control and tetanus prophylaxis.
laryngoscopy/ bronchoscopy. If the carboxyhemoglobin level is > 5-10% than 100%
oxygen should be administered. Circumferential burns
Diagnosis
need escharotomy. Stress ulcer prophylaxis with H2
Visible skin injury is estimated with the "Rule of Nines" in blockers should be given. Never break blisters. Skin grafting
adults in which head and arms are 9% of body surface is done on the basis of the size and severity of the injury.
area (BSA) each and chest, back, and legs are 18% of BSA Steroids are not indicated in burns.
6 The Definitive Review of Medicine for USMLE
Treatment Hypothermia
Asymptomatic non-high tension voltage (< 1000 V) burn It is a state in which the body's mechanism for temperature
patients may go home. Fluid administration should be in regulation is overwhelmed in the face of a cold stressor.
Table 1.1
Heat cramp Due to fluid and water depletion, which Body temperature normal Rest, oral rehydration, and
lead to painful muscle contraction. with no neurological salt replacement.
Patient sweats complaints muscles usually
tender
Heat exhaustion Severe than heat cramp with more Body temperature slightly Oral fluid and liquid
systemic symptom. Patient sweats elevated with headache and replacement. IV fluid in severe
profusely. anxiety weakness. Progression to
heat stroke if not treated.
Heat stroke Very severe and life threatening. No Very high body temperature Place in cool environment,
sweating. Blurred vision, confusion, (> 40oC). Elevated BUN, rapid cooling with water spray,
disorientation, seizure. Complication of creatinine. fanning, IV fluids. If shiver
lactic acidosis, DIC, anuria. Hemocon-centration starts, give diazepam and
Rhabdomyolysis. chlorpromazine. Ideally
decrease temperature by 0-2o/
minute
Malignant Idiosyncratic reaction to any anesthetic Tachycardia high Dantrolene
hyperthermia agent or succinylcholine. Muscular temperature
rigidity. Rhabdomyolysis.
Hypercapnia.
Neuroleptic Idiosyncratic reaction to Rhabdomyolysis. History of Stop the drug.
malignant phenothiazines, haloperidol. Muscular drug administration. Dantrolene/bromocriptine.
syndrome rigidity
Emergency Medicine 7
Core body temperature, measured rectally or through '99er'- Intoxicated patient- with life threatening injury,
esophagus is < 35C. It is seen commonly in elderly should be first physically constrained and then treated.
alcoholics. Hypothermia progressively depresses the CNS,
decreasing CNS metabolism in a linear fashion as the core Radiation Injury
temperature drops and therefore is one of the few It is damage to the body caused by ionizing radiation
conditions in which a patient can be resuscitated from through destructive changes to DNA molecules, especially
pulselessness beyond 10 minutes. in rapidly dividing cells. Bone marrow depression is most
common cause of death in these patients due to infection
Frost Bite and bleeding (from thrombocytopenia). Leukemia may
It is characterized by freezing of tissue. According to skin occur because of radiation. Cells in descending order of
involvement and severity, they are classified as: sensitivity to radiation are lymphocyte (at 2-3 Gy/200-
First-degreeErythema, edema, waxy appearance, 300 rad), neutrophils, red cells. GI symptoms include
hard white plaques, and sensory deficit nausea and vomiting initially and may progress to
Second-degreeFormation of blisters, which are filled intestinal ulcerates, leading to bleeding and infection as
with clear or milky fluid. dose of radiation increase.Effect on testis may cause
Third-degreeBlood-filled blisters present, which temporary aspermatogenesis and more radiation can make
progress to a black eschar. men permanently sterile.
Fourth-degreeFull-thickness damage affecting Treatment
muscles, tendons, and bone. Non viable structures
The management is symptomatic as no cure is available.
demarcate and slough off.
There is no specific therapy to reverse radiation injury.
Clinical Features
DROWNING
Companion of hypothermic patient give history of mood
change, irritability, poor judgment, and lassitude in Results in primary respiratory impairment from submer-
patient. He may have also shown paradoxical undressing sion in a liquid medium. Factors that predispose to
(a severely hypothermic person removes clothing in drowning include alcohol and illicit drugs ingestion,
response to prolonged cold stress) or rhythmic or repeated neurological trauma, acute MI, exhaustion, etc. Pathophy-
motions such as rocking. Hypothermia results in decreased siologically drowning in water may be:
depolarization of cardiac pacemaker cells, causing
Fresh Water Drowning
bradycardia. Since this bradycardia is not vagally
mediated, it can be refractory to standard therapies such Fresh water moves rapidly across the alveolar-capillary
as atropine. Mean arterial pressure and cardiac output membrane into the microcirculation and hence causes acute
decreases and atrial and ventricular arrhythmias also hypervolemia, hemodilution, and intravascular hemolysis.
occur, of which ventricular fibrillation is most common. Surfactant is destroyed and hence produces alveolar
instability, atelectasis, and decreased survival chances in
Diagnosis fresh water drowning.
ECG shows various arrhythmias along with characteristic Salt Water Drowning
J or Osborne waves (occasionally also seen in sepsis and Hypertonic water draws water into alveoli and makes them
myocardial ischemia). more fluid filled and heavy. This leads to decrease in
compliance, damage of alveolar-capillary basement
Treatment membrane, and shunting, which results in rapid induction
Patient should be warmed by putting him in a warm bed, of serious hypoxia.
bath, or covering them with heating blankets. Severe cases
Clinical Features
may require warm IV fluids or oxygen. Resuscitative
measures should be continued, even in presence of life Near drowned patients present with coughing with blood
threatening arrhythmias, till temperature is > 35C. tinged sputum, cyanosis, and tachypnea. On examination
Bretylium is drug of choice for ventricular fibrillation. patient may be agitated or in coma.
8 The Definitive Review of Medicine for USMLE
Table 1.3
Toxin Clinical feature Diagnosis Treatment
Acids (various Alkali exposure more severe than acid History + upper Immediate washout with
household exposure. Oral pain, odynophagia, endoscopy to determine cold water. No forced
cleaners)/alkalis abdominal pain, strictures, drooling extent of damage emesis. No neutralization of
(lye, detergents) acid/base.
Acetaminophen Nausea, vomiting followed by asymptomatic AST elevation more N-acetylcysteine (specific
period of up to 2 days and then signs of liver common than ALT antidote). Effective only if
failure and even renal failure elevation. Draw a given up to 36 hours of
nomogram against time ingestion. Give repeated
to see if patient may activated charcoal also
develop toxicity
Barbiturate Hypothermia, loss of deep tendon reflexes, Patient may even have Forced diuresis with
corneal reflex. Severe CNS and respiratory silent EEG if severe bicarbonates.
depression that may even cause death depression
Methanol (solvents, Visual disturbance to blindness Metabolic acidosis with Ethanol infusion.
windshield (due to formic acid) elevated anion gap. Hemodialysis if severe
washers, paint Also seen in ethylene symptoms. Fomepizol
thinner, sterno) glycol. (alcohol dehydrogenase
inhibitor) is specific
antidote.
Ethylene glycol Nausea, vomiting, kussmaul breathing, Oxalate crystal in urine, Same as methanol
(Automotive slurred speech, flank pain, pulmonary elevated BUN/creatinine,
antifreeze) edema, renal failure, oxalate crystals woods lamp fluorescein,
in urine, stones in urine. hypocalcemia
Carbon monoxide Neurologic: confusion, throbbing headache, Find out Removal from source,
(CO) (low level CO dizziness, impaired judgment. (period) carboxyhemoglobin 100% oxygen, hyperbaric
poisoning in most Pulmonary: dyspnea, tachypnea. (period) level, ABG- metabolic oxygen in severe cases.
smokers) Cardiac; chest pain, hypotension. Nausea, acidosis, CPK elevated Patient suffers silent death.
malaise
Digoxin GI symptoms, blurred vision, yellow vision, ECG- arrhythmias, most Repeated charcoal, correct
(predisposed by hallucination, confusion, arrhythmias common is paroxysmal hypokalemia; phenytoin or
hypokalemia) atrial tachycardia (along lidocaine for arrhythmia,
with vision alteration digoxin specific antibodies
diagnosis clincher)
Hallucinogens Anticholinergic effects. PCP (angel dust)may History and presentation Benzodiazepines. Low
(marijuana, LSD, cause seizure and death sensory environment for
mescaline, PCP intoxication
psilocybine)
Contd...
Emergency Medicine 11
Lead (question Adult: abdominal pain, anemia, headache, First test to be done Removal from exposure
typically has memory loss, renal diseaseChildren: acute- include CBC, serum Fe, site.
children residing in abdominal pain, anemia, lethargy, seizure. ferritin, reticulocyte
very old homes Chronic-poor cognitive and behavioral count. Also measure
where they eat paint function, mental retardation, lead lines on blood lead level. Patient
flakes) metaphyseal plates. shows anemia, azotemia.
Mercury GI symptoms, interstitial pneumonitis (if From history Removal from source.
inhaled); erethism- tremors, excitability, Chelation with succimer,
memory loss, delirium , insomnia dimercaprol, and
pencillamine
Opiates Respiratory depression (diagnosis clincher), Needle tracks on skin, Naloxone (specific
miosis, constipation, hypothermia, history and presentation antidote)
bradycardia
Salicylates (aspirin) GI symptom (most common), tinnitus Early on respiratory Gastric lavage, repeated
(diagnosis clincher), hyperventilation, alkalosis but later charcoal. Mainstay is
hyperthermia, confusion, seizure, coma metabolic acidosis with alkalization of urine.
elevated anion gap. Dialysis if severe.
Aspirin level
Tricyclic Anticholinergic effects, QRS prolongation Serum drug levels, ECG Gastric lavage helpful here
antidepressants (diagnosis clincher) leading to ventricular findings even after 1 hour of
(one of the most tachycardia, atrial arrhythmias, conduction ingestion. Any cardiac sign-
common suicidal blocks immediate bicarbonate
drug in depressive
patients)
Table 1.4
Drug Symptoms Treatment
'99er'- Acute alcoholic intake can reduce the risk of Delirium Tremens (DT)
hepatic injury due to Acetaminophen because it competes
DT usually begins 24-72 hours after last ethanol use. It is
with CYP2E1, so there is less production of toxic
characterized by extreme agitation along with altered
metabolites. Chronic alcohol intake increases risk of
hepatic injury by stimulating P450 system and decreasing mental status symptoms like confusion, delusions,
hallucinations, and severe agitation, or generalized
the amount of Glutathione (used for metabolism of
seizures. There is increased sympathetic nervous system
acetaminophen).
activation. Morbidity and mortality from DT is due to
'99er'-Lead poisoning- treatment therapy: Blood levels
hyperadrenergic state and associated medical problems
< 45 g/dL- DMSA/d-pencillamine; 45-70 g/dL- IV
like infections, fluid and electrolyte abnormalities. The
EDTA/ oral DMSA; > 70 g/dL (may present as
major goal is to blunt the hyperadrenergic state and treat
encephalopathy) - dimercaprol + EDTA.
associated medical problems. IV saline, thiamine, glucose,
'99er'- Isopropyl alcohol- develops ketosis but without and benzodiazepines are the main stay of treatment.
elevated anion gap as in methanol and ethylene alcohol. Ethanol withdrawal seizures typically occur 6-48 hours
'99er'- Unknown chemical on skin- first thing to be after the last drink.
done in such a case is to flush the skin with copious amount '99er'- Anaphylaxis- in severe anaphylaxis, treat with
of low pressure water. 0.3-0.5 ml of 1:1000 IV epinephrine. If its only mild
'99er'- When a patient takes Lye (alkali substance for (subcutaneous reaction), than give subcutaneously.
suicide), upper GI contrast studies should be performed '99er'- Postanaphylaxis- Most important intervention
as early as possible, to assess the damage and possible is teaching proper use of epinephrine pen.
perforation of esophagus. Normal X-Ray does not rule out '99er'- Venomous bites- Patient should be immobilized
a perforation. Once you know there is no perforation then to limit spread of venom and a compression bandage be
you can do diagnostic peritoneal lavage if necessary. But tied, but a tourniquet is not indicated. ABC should be
the first thing is to rule out perforation. maintained and an antivenin given.
Chapter
2 Infectious Diseases
Signs Treatment
Kernig sign: In a supine patient, flex the hip to 90
Table 2.3
while the knee is flexed at 90. An attempt to further
extend the knee produces pain in the hamstrings and Predisposing feature Common pathogens
resistance to further extension. Age 0-4 weeks Group B or D streptococci, E. coli,
Brudzinski sign: Passively flex the neck while the Listeria
patient is in a supine position with extremities
Age 1-3 months From both above and below group
extended. This maneuver produces flexion of the hips
in patients with meningeal irritation. Age 3 months to S. pneumoniae, N meningitidis, and
50 years H influenzae.
Symptoms in Infants
Older than 50 years S. pneumoniae, H. influenzae,
Fever Listeria species, Pseudomonas
Lethargy and/or change in level of alertness aeruginosa, and N. meningitidis.
Poor feeding and/or vomiting
Impaired cellular Cryptococci, Mycobacterium
Respiratory distress, apnea, cyanosis
immunity tuberculosis, syphilis, HIV aseptic
99er- The most common long-term neurologic deficit meningitis, and Listeria species
is damage to the 8th cranial nerve. Facial nerve palsy is
suggestive of Lyme. Neurosurgery, head Staphylococcus epidermidis,
trauma, or CSF shunt S. aureus, coliforms, Propionibac-
terium acnes.
Diagnosis
The cornerstone in the diagnosis of meningitis is
examination of the CSF. CT scan of the brain may be Table 2.4
performed prior to lumbar puncture in some patient groups Pathogen Treatment
with a higher risk of herniation, which include those with:
S. pneumoniae Vancomycin + III generation cephalo-
newly onset seizures
sporin (+dexamethasone- not always)
an immunocompromised state L. monocytogenes Ampicillin
signs suspicious for space-occupying lesions (such S. agalactiae Ampicillin
as papilledema and focal neurologic signs) N. meningitides Ampicillin/ III generation cephalosporin
moderate-to-severe impairment in consciousness H. influenzae III generation cephalosporin
If the lumbar puncture is delayed more than 20-30
minutes for any reason, then the best initial step is to give
an empiric dose of antibiotics with ceftriaxone or
General Principle in Treatment
cefotaxime. Also begin empiric therapy prior to head CT Suspected meningitis should be treated immediately,
scan if a focal neurologic deficit is present. and do not wait for LP results.
Table 2.2
WBC count/L Glucose (mg/dL) Protein (mg/dL) Confirmatory test
Normal 0-5; lymphocytes 50-75 15-40
Bacterial 100-5000;>80% PMNs <40 >100 Gram stain, culture (better results)
Viral 10-300;lymphocytes Normal, reduced in Normal, but may be Viral isolation, PCR analysis
mumps, Lassa virus slightly elevated
Tuberculous 100-500; lymphocytes Reduced; <40 Elevated;>100 AFB staining, culture, PCR
Empiric therapy of bacterial meningitis is best elevated ICP, obstructive hydrocephalus, or mass
achieved with ceftriaxone or cefotaxime. effect. HSV has a predilection for involvement of the
Ampicillin is added to those with immune defects to temporal lobes, therefore presenting with behavioral
cover Listeria. Listeria is resistant to all forms of abnormality, which can be seen on CT.
cephalosporins. MRI: more likely to show abnormalities earlier in
Lyme disease: ceftriaxone. disease course than head CT.
Cryptococcus: initially with amphotericin; lifelong LP: CSF examination may be helpful.
fluconazole therapy in HIV-positive patients. Polymerase chain reaction (PCR for HSV): has
Syphilis- penicillin. eliminated need for biopsy and is very sensitive and
TB meningitis: in the same fashion as you would use specific.
for pulmonary TB. Steroid use in adult meningitis is
only appropriate for TB meningitis. Treatment
Viral (or aseptic) meningitis: no treatment currently
proven useful for. With the important exceptions of HSV and varicella-zoster
encephalitis, the viral encephalitides are not treatable
Prophylaxis beyond supportive care. Treatment with the relatively safe
acyclovir should be initiated in any patient who presents
For close contacts of patients with (suspected) with encephalopathy and focal findings, has no apparent
N. meningitides by rifampin (same for suspected explanation and in all neonates who appear ill and are
H. influenzae). Indicated for those at increased risk, such as
without a final diagnosis. HSV encephalitis is best treated
those who were in close contact with patient for at least
with IV acyclovir for 14-21 days. Ganciclovir or foscarnet
4 hours during the week before onset or were exposed to
can be used against CMV.
patients nasopharyngeal secretions.
99er- Primary HSV 1 infection most frequently
presents with gingivostmatitis and pharyngitis along with
ENCEPHALITIS
fever, malaise, myalgias and cervical adenopathy. The
It is an inflammation of the brain parenchyma, which lesions are vesicular with erythematous base. It is usually
presents as diffuse and/or focal neuropsychological seen in children and young adults.
dysfunction. Meninges involvement is common and most 99er- HSV1 encephalitis- is usually due to
cases are due to viral infection (HSV most common), though reactivation. HSV is suspected in patient when he presents
other pathogens may also be involved. with bizarre behavior, gustatory and olfactory hallucina-
Cerebritis describes the stage preceding abscess tions, acute hearing impairment, and speech disorder.
formation and implies a highly destructive bacterial Get HSC PCR done on CSF.
infection of brain tissue. 99er- Acyclovir Toxicity: Can cause crystalluria with
Clinical Features renal tubular obstruction during high dose parenteral
therapy, especially in inadequately hydrated patients.
A patient presenting with fever, headache along with
altered mental status (diagnosis clincher) should always be
suspected for encephalitis. The classic presentation, along BRAIN ABSCESS
with focal signs, includes the following:
Most brain abscesses originally stem from nasopharyngeal
Behavioral and personality changes, decreased level
of consciousness infections such as otitis media, mastoiditis, and sinusitis,
Stiff neck, photophobia, and lethargy or dental infection. Apart from this contiguous spread,
Generalized or localized seizures (common in children infection from pneumonia or endocarditis can also reach
with California encephalitis ) brain hematogenously.
Acute confusion or amnestic states Brain abscesses are commonly polymicrobial and the
Flaccid paralysis (10% with West Nile Encephalitis) most common involved pathogens are Streptococcus,
bacteroides, Staphylococcus, enterobacteriacae, etc.
Diagnosis Toxoplasmosis is commonly encountered and may lead
Head CT, with and without contrast- in all patients to abscess formation in AIDS patient in whom CD4 count
with encephalitis before LP to search for evidence of < 50-100.
16 The Definitive Review of Medicine for USMLE
in diabetics and poor control of serum glucose (> 300 mg/ is the surgical procedure of choice for the treatment of
dL). Therefore, along with antibiotic for infection, start chronic sinusitis.
immediate steps to control glucose by an insulin control.
Pharyngitis
Treatment
It is an infection or irritation of the pharynx and/or tonsils.
Any foreign material may be removed from canal and start Viruses cause majority of infections, but group A beta-
topical antibiotic like ofloxacin along with steroids. hemolytic streptococcal (GABHS) infections are clinically
most significant because of the fact that they have serious
Sinusitis sequelae like rheumatic fever or glomerulonephritis.
Sinusitis is the inflammation/infection of 1 or more
Clinical Features
paranasal sinuses (most commonly maxillary sinus) and
occurs due to obstruction of the normal drainage The chief symptoms of pharyngitis include:
mechanism. It is traditionally subdivided into: Sore throat
Acute: symptoms lasting < 3 weeks Pain when swallowing
Subacute: symptoms lasting 3 wk to 3 months Fever
Chronic: symptoms lasting > 3 months Enlarged lymph nodes in your neck
Etiologically sinusitis has same pathogens like otitis Streptococcus pyogenes: Fever, cervical adenopathy
media. In chronic sinusitis, the infecting organisms are with exudative covering (also EBV).
variable, and a higher incidence of anaerobic organisms Adenovirus: Conjunctivitis associated with
(Bacteroides, Peptostreptococcus, and Fusobacterium species) pharyngitis (pharyngoconjunctival fever). Most
is seen. common etiology in children younger than 3 years.
Herpes simplex: Vesicular lesions (herpangina),
Clinical Features especially in young children, are the hallmark.
Coxsackie viruses A and B: If vesicles are present
Patients typically complains of facial pain, diagnosis
and are whitish or nodular, it is known as
clincher headache (that worsens on leaning forward or
lymphonodular pharyngitis.
any head movement), tooth pain, fever, postnasal drainage,
Epstein-Barr virus (EBV): Clinically known as
alteration in smell, and purulent nasal drainage. Patients
infectious mononucleosis, it is extremely difficult
may complain of retro-orbital pain if the ethmoid sinus is
to distinguish from GABHS infection. Exudative
involved.
pharyngitis is prominent. Distinctive features
include retrocervical or generalized adenopathy
Diagnosis
and hepatosplenomegaly. Atypical lymphocytes
Uncomplicated sinusitis is often diagnosed clinically. can be seen on peripheral blood smear.
Maxillary sinus X-rays are the best initial test but in some CMV: Similar to the presentation of infectious
institutes, CT scan is now first modality to be used. CT mononucleosis. Patients tend to be older, are
scan with bone window is imaging modality of choice in sexually active, and have higher fever and more
chronic sinusitis. Non-responders/recurrent cases may malaise. Pharyngitis may not be a prominent
have to undergo sinus puncture and culture. complaint. Should be highly suspected when
patient has lymphadenopathy along with malaise
Treatment (diagnosis clincher)
HIV-1: Associated with pharyngeal edema and
It is aimed at blocking the inflammatory reactions in mild erythema, common aphthous ulcers, and a rarity
cases by decongestants (oral pseudoephederine), while of exudates. Fever, myalgia, and lymphadeno-
antibiotics (same as in otitis media) should be given to pathy also are found.
eliminate the infection in acute bacterial sinusitis. Chronic 99er Coxsackie virus A16 may cause hand-foot-and-
sinusitis is to be treated with amoxicillin+/- clavulunate mouth disease, which presents with 4- to 8-mm
for 21 days. Functional endoscopic sinus surgery (FESS) oropharyngeal ulcers and vesicles on the hands and feet,
18 The Definitive Review of Medicine for USMLE
99er Vaccination in symptomatic patient: It takes Esophageal disease (reflux disease, achlasia)
2 weeks to mount response. By then zanamavir, amantadine Bronchial obstruction (tumor, foreign body)
and rimantadine is started within 30-48 hour of onset of Generalized sepsis.
symptom. After that acetaminophen should be given.
Clinical Features
LUNG INFECTION
These patients typically have an intermittent febrile course,
productive cough, weight loss, general malaise, and night
Bronchitis
sweats. Initially, foul sputum is not observed in the course
It refers simply to inflammation of the tracheobronchial of the infection; however, after cavitation, putrid
tree. Acute bronchitis is often caused by the same viruses expectorations are quite prevalent. The odor of the breath
that cause colds. Chronic bronchitis is one type of COPD. and sputum of a patient with an anaerobic lung abscess is
The most common organisms responsible are similar to often quite pronounced and noxious (diagnosis clincher).
those causing sinusitis and otitis media. Cigarette
smoking is the most common cause. Breathing in other Diagnosis
fumes and dusts over a long period of time may also cause
Expectorated sputum evaluation: It is the first step in
chronic bronchitis.
the diagnosis of a patient with a lung abscess. Gram
stain and culture should be performed, though in
Clinical Features
typical anaerobic lung abscess, sputum analysis is
A purulent cough generally is the defining presentation not useful but the analysis is helpful to exclude other
for acute bronchitis. Patient may also present with malaise, causes of lung abscess.
low grade fever, wheezing, rales, dyspnea and chest pain. X-ray: Shows a thick-walled cavitary lesion. An area
of thick pneumonic consolidation precedes the
Diagnosis emergence of the typical cavitary air-fluid form.
A patient with cough and sputum but clear lungs on Site of aspiration in upright position is lower lobes
of right lung (most common site of aspiration
X-ray is quite diagnostic of bronchitis.
pneumonia) and the posterior segment of the right
upper lobe is the most common site in the supine
Treatment
position.
Therapy is generally symptomatic and includes use of CT scan: helps define the exact extent of the cavity.
analgesics, antipyretics, antitussives, and expectorants.
Severe infections are treated by amoxicillin, doxycycline, Treatment
or TMP/SMZ. Non-responders should be treated with
Clindamycin is empiric drug of choice in typical anaerobic
amoxicillin/clavulanate, clarithromycin, azithromycin,
infection. Penicillin is a good alternative.
oral II/III generation cephalosporins, or the new
fluoroquinolones.
PNEUMONIA
Typical: S. pneumoniae (most common) and Haemophilus involvement and also by lack of localizing symptoms. Most
and Staphylococcus species. frequent causative infection is Mycoplasma.
Atypical: Usually do not show up on culture 99er-To prevent future episodes of aspiration, speech
Zoonotic-Chlamydia psittaci (psittacosis), therapy and swallowinfg evaluation required. This should
Francisella tularensis (tularemia), and Coxiella be followed by diet modification.
burnetii (Q fever). 99er-Mycobacterium avium complex is present in the
Nonzoonotic- Chlamydia pneumoniae, Mycoplasma water supply in most areas of the United States and
pneumoniae, and Legionella pneumonia. Mycobacterium avium complex hypersensitivity
Aspiration pneumonias are mostly due to aspiration pneumonitis is associated with use of hot tubs.
of microorganisms from oral cavity, pharynx. Aspiration
pneumonitis shows no sign of infection since it is just a Clinical Features
chemical injury and lung parenchyma inflammation Pneumonia typically presents with acute onset of fever,
(Mendelson syndrome). chills, productive cough and pleuritic chest pain (diagnosis
Atypical pneumonias are characterized by clincher). The character of sputum produced may suggest
predominantly interstitial, rather than intra-alveolar a particular pathogen like:
Table 2.5
Predisposition Causative agent
Exposure to contaminated air-conditioning cooling towers, store mist Legionella
machine, contaminated water system, epidemic in older smokers
Overcrowded institutions such as jails, shelters for homeless persons, S. pneumoniae, Mycobacterium tubercu-
or military training camps losis, Mycoplasma, and Chlamydia
Significant purulent sputum: Streptococcus pneumonia, young patient. Patient presents with headache, low grade
Haemophilus, and Klebsiella fever, atelectasis of lungs, and cold agglutinins.
Bloody or rust-colored sputum: Streptococcus pneumonia 99er-Chlamydia psittaci infection- is characterized
Green sputum: Pseudomonas by triad of meningioencephalitis, splenomegaly, and
Foul-smelling and bad-tasting sputum: Anaerobic pneumonia. Patients occupation is very important clue to
infections diagnosis (diagnosis clincher). Radiologically it shows
Currant-jelly sputum- Klebsiella consolidation in lower lobes.
On physical examination pneumonia presents with
rales, rhonchi, or signs of lung consolidation like dullness Diagnosis
to percussion, decreased intensity of breath sounds,
egophony upon auscultation, whispering pectoriloquy. Chest X-ray
Lobar pneumonia is the type most commonly associated
It is always the initial test in presence of pulmonary system
with signs of consolidation on examination. Altered mental
involvement and shows consolidation in lungs, which
status may also be seen.
may be lobular or interstitial (PCP, viral, Mycoplasma,
Dry cough is observed in pathogens that cause
Chlamydia, Coxiella, Legionella).
interstitial infections like Pneumocystis pneumonia (PCP),
viruses, Mycoplasma, and sometimes Legionella. Patient may A segmental or lobar opacity with air bronchogram -
report rigors or shaking chills and nonspecific symptoms S. pneumoniae pneumonia
like headaches, myalgias (walking pneumonia) malaise, Cavitary lesions and bulging lung fissures -
nausea, vomiting, and diarrhea. K. pneumoniae or S aureus
Tachypnea (>18 breaths/minute) is a major feature and Presence of cavitation and associated pleural effusions
very important indicator of severity of pneumonia. - S. aureus, anaerobic infections, gram-negative
Progression in severity of pneumonia is matched by degree infections, and tuberculosis
of hypoxia, which leads to tachypnea and hyper- Predilection for the lower lung fields- Legionella
ventilation. Tendency to involve the upper lung zones- Klebsiella
99er-Bullous myringitis- is due to mycoplasma Round pneumonia (often presents as solitary
infection and is characterized by presence of erythematous, pulmonary nodule) - C. burnetii, S. pneumoniae,
painful papules on surface of tympanic membrane of a L. pneumophila, S. aureus.
Table 2.6
Absent gag reflex, altered level of consciousness, recent Polymicrobial (aerobic and anaerobic), possible
seizure macroaspiration or microaspiration
Ethambutol is associated with optic neuritis, which treatment. Patient with positive PPD (latent disease) but
can cause color blindness and other visual no evidence of active disease (and with normal X-ray) are
disturbances. required to take a 9 month therapy with isoniazid and vitamin
PZA can cause a benign hyperuricemia. Dont treat B6.
the hyperuricemia unless there are symptoms of gout
associated with it, which rarely occurs.
GASTROINTESTINAL INFECTIONS
Pregnant patients should not receive PZA or
streptomycin.
Infectious Diarrhea
Screening and Latent TB Acute infectious diarrhea is defined as the abrupt onset of
abnormally high fluid content in the stool (> 10 mL/kg/d)
PPD testing is used to screen asymptomatic populations due to infection from a pathogen.
at risk of TB and usually is not used to diagnose TB in an Diarrhea lasting 2-4 weeks is classified as persistent.
acutely ill patient unless all other tests have been Chronic diarrhea is defined by duration of more than
performed. Amount of induration of skin, 48-72 hours after 4 weeks.
intradermal injection of 0.1mL dose of 5 TU PPD, is noted Food poisoning is defined as an illness caused by the
and is the parameter for interpretation of results. The results consumption of food or water contaminated with bacteria
are interpreted as positive and patient is labeled to have and/or their toxins, parasites, viruses, or chemicals and
latent TB in following cases: may involve vomiting along with diarrhea.
> 5 mm in HIV positive, have abnormal chest Common bacteria causing infectious diarrhea and their
radiography, steroid use or organ transplantation mechanism are as under:
recipients, or have recent contact with active TB cases. Toxigenic (Enterotoxin binds small bowel: secretory)
> 10 mm in IV drug users, residents of nursing homes, Enterotoxigenic E. coli (most common)
health care workers, prisoners, recent immigrants, Yersinia enterocolitica
immunocompromised patients (apart from those Shigella
mentioned above)and impoverished and homeless Vibrio cholerae (classic example)
population. Aeromonas
> 15 mm in young people, in good health Cytotoxic (Cytotoxin: Cell damage and inflamma-tion)
Adults who received BCG vaccination at birth, Enteropathogenic E. coli
induration > 10 mm is positive. Enterohemorrhagic E. coli
Persons who received BCG vaccination as adults, Shigella
induration > 30 mm is considered positive. Clostridium difficile
Patients with latent tuberculosis are not infectious and Adherent
it is not possible to get TB from someone with latent Enteropathogenic E. coli
tuberculosis. Patients who dont have history of recent Enterohemorrhagic E. coli
PPD testing and present with induration < 10 mm, should Invasive (Colonize, Adhere, and Invade. Dysentery-
undergo another PPD 2 weeks later, as it might be a false blood in stool)
negative test. Non-typhoidal Salmonella
Once patients induration is interpreted as positive, he Yersinia enterocolitica
should follow it up with chest X-ray. If some abnormality Shigella
is detected on X-ray than it should be followed by three Vibrio parahaemolyticus
AFB sputum stains, which will indicate presence or Campylobacter jejuni
absence of active disease. Positive AFB is indicative of In US most common cause of infectious diarrhea is
active disease and of need to start complete 4 drug Campylobacter.
Infectious Diseases 25
Clinical Features
Table 2.8 Table 2.9
Associated features Organisms Clinical features Pathogens
Fried rice Bacillus cereus Guillain-Barre syndrome Campylobacter
Dairy Campylobacter and Salmonella Hemolytic uremic syndrome E. coli 0157:H7, Shigella
species
Severe GI symptoms 2-8 hours Coagulase negative
Fresh water/camping Giardia lamblia, cryptosporidiosis after ingestion and recover Staphylococcus
Eggs Salmonella species within 12 hours
Bacterial culture for enteric pathogens becomes Listeria infection: Intravenous ampicillin or TMP-SMZ
mandatory if a stool sample shows positive results for is administered to treat systemic Listeria infection
WBCs or blood or if patients have fever or symptoms 99er-Giardia in pregnancy- Drug of choice in 2nd
persisting for longer than 3-4 days. trimester is pramomycin, otherwise metronidazole.
Microscopic examination of the stool for ova and 99er-Bacterial overgrowth Syndrome (BOS): occurs
parasites should be done (giardia, cryptosporidia). when the normally low bacterial colonization in the upper
A special modified AFB stain is necessary to detect GI tract significantly increases and is mostly seen after GI
Cryptosporidia. Assay for C. difficile to help rule out surgeries. Patient usually will present with mild abdominal
antibiotic-associated diarrhea in patients receiving distention, discomfort, bloating, or flatulence after food
antibiotics. ingestion. Gold standard for diagnosis is quantitative jejuna
cultures. Alternate is 14C d-xylulose test. Treatment
Treatment involves tetracycline in known causes of BOS and
metronidazole/clindamycin for idiopathic BOS.
The major determinant of the type of therapy is the severity 99er-Chronic diarrhea- patient evaluation should
of the disease in each individual patient. Mild infections contain complete history followed by stool analysis.
can be treated with oral fluid and electrolyte replacement.
More severe infections (high fever, abdominal pain,
hypotension, and tachycardia), travelers diarrhea, or ACUTE VIRAL HEPATITIS
dysentery require intravenous fluids and oral antibiotics. Viral hepatitis is an infection of the liver caused by one of
A 5-day course of a fluoroquinolones is the first-line the hepatitis A-E and G viruses.
therapy. TMP/SMX is an alternative therapy. Various Hepatitis viruses and their characteristics
Organism specific therapy is as follows:
99er-Hepatitis C infection- is the most common cause
Campylobacter- Azithromycin, Erythromycin
of acquired mixed cryoglobulinemia. Screen for hepatitis
GiardiaMetronidazole
C in patients who have vasculitis plus elevated
Amebiasis- Metronidazole followed by paromomycin/
cryoglobulin.
iodoquinol.
CryptosporidiumControl of the underlying HIV 99er-Transaminase levels elevated > 10-20 times of
disease with antiretroviral drugs. Paromomycin is normal- in acute viral hepatitis, ischemia (shock liver),
considered in severe cases. or toxins. Moderate elevation is seen in chronic viral
C. difficileMetronidazole; vancomycin if it fails. hepatitis, nonalcoholic fatty liver disease, or autoimmune
ScombroidAntihistamines such as diphenhy- involvement, etc.
dramine. Window period: Is the time period of 2-6 weeks when
Cyclosporiasis- TMP-SMZ may be an effective there is no detectable HBsAg and Anti HBs has not yet
treatment for the immunocompromised host. developed.
Fig. 2.1
Infectious Diseases 27
Severity Mild May be severe Usually subclinical Co-infection with B Mild (except pregna-
ncy where it may be
fatal)
Transmission Fecal-oral Parenteral, sexual Parenteral, sexual Parenteral, sexual Fecal-oral (food
(food borne) borne)
Symptom Anorexia, malaise, Few may develop Just 20% are Same as A Same as A
fever, vomiting, serum sickness like acutely symptomatic
headache, dark features of rash,
urine, jaundice joint pain. Else
like A
Chronicity (%) 0 5-10 80 (very common) - 0
usually are secondary to bone pain, which is described penicillin G, 2.4 million U IM once weekly for 3
as a deep boring pain characteristically worse at night. consecutive weeks.
This stage is symptomatic, but not contagious. Trauma Neurosyphilis- Aqueous crystalline penicillin G, 2-4
may predispose a specific site to gumma involvement. million U IV q4h for 10-14 days
CNS involvement may occur, with presenting Penicillin allergic tertiary stage patient or pregnant
symptoms representative of brain (headache, patient with syphilis need to be undergo desensitization
dizziness, mood disturbance, neck stiffness, against penicillin and then should be treated with it.
blurred vision) and spinal cord involvement Patient should be informed about the possibility of a
(bulbar symptoms, weakness and wasting of Jarisch-Herxheimer reaction that may occur at the outset
shoulder girdle and arm muscles, incontinence, of treatment with penicillin. Patients may develop transient
impotence). Some patients may present up to 20 fever and symptoms such as malaise, chills, headache,
years after infection with behavioral changes and and myalgias. Existing lesions may intensify temporarily.
other signs of dementia, which is indicative of The reaction is quite common, develops within several
development of neurosyphilis. hours after beginning antibiotic treatment, and usually
The Argyll Robertson pupil (usually only with clears within 24 hours, with no treatment required. It has
neurosyphilis) is a small irregular pupil that reacts no effective prevention also.
normally to accommodation but not to light. 99er HIV in syphilis patient- if syphilis is of unknown
Tabes dorsalis (locomotor ataxia) results in pain, duration or is latent for 1 year, patient should undergo
ataxia, sensory changes, and loss of tendon CSF examination before treatment. Treatment is benzathine
reflexes. penicillin G IM weekly for 3 weeks.
Cardiovascular syphilis usually begins as an HIV patient with neurosyphilis/ocular syphilis:
inflammation of the arteries leading from the heart aqueous crystalline penicillin G IV for 2 weeks. In penicillin
and causes heart attacks, scarring of the aortic allergic patient, ceftriaxone is given. If intolerant to both,
valves, congestive heart failure or the information give tetracycline.
of an aortic aneurysm.
Congenital: A small percentage of infants infected in COMMON STD (Table 2.11)
utero may have a latent form of infection that becomes 99er-Chlamydia infection is so common that it is
apparent during childhood and, in some cases, during recommended to be treated along with gonorrhea by 1gm
adult life. The earliest symptom that occurs prior to PO azithromycin/ 7 day oral doxycycline. But it is not
age 2 years is rhinitis (snuffles), soon followed by true other way round. All sexual contacts, whether
cutaneous lesions. After age 2 years, parents may note symptomatic or not, should be examined, cultured, and
problems with the childs hearing and language treated. Gonorrhea cases also need tobe reported to
development and with vision. Facial and dental concerned public health officer.
abnormalities may be noted. 99er-Condyloma acuminata: is the most common viral
STD and presents as genital warts. Complete sexual
Diagnosis history is required as a history of receptive anal intercourse
Screening tests are the VDRL (false positive with EBV, may indicate anoscopy for intra-anal warts. Women with
collagen vascular disease, TB, subacute bacterial genital warts should undergo a pap smear to detect cervical
endocarditis), and RPR; specific tests are the FTA-ABS, dysplasia. It may be confused with pearly penile papule
MHA-TP. Darkfield exam of chancre shows spirochetes. which is a common variant and is not considered a
Perform a LP when neurological or ophthalmological signs pathology.
and symptoms are present, in treatment failure, signs and 99er-CDC guidelines for STD treatment recommends
symptoms for >1 year, or when VDRL of > 1:32 is present. offering hepatitis B vaccine to all the patients being treated
for STD.
Treatment
GENITOURINARY TRACT INFECTION
Primary, secondary, and early latent syphilis ( <1 y
duration)- Single dose of benzathine penicillin G, Cystitis
2.4 million U IM. Alternative is doxycycline or
erythromycin for 14 days. It is infection of the urinary bladder, which is very common
Late latent syphilis (>1 y duration), syphilis of in women. It may be caused by any foreign body (catheter)
undetermined duration, and late syphilis- Benzathine in the tract or any factor that causes stasis of urine like
30 The Definitive Review of Medicine for USMLE
Table 2.11
Chancroid (Haemophilus Small, painful, shallow genital ulcers Clinically. Gram stain, Azithromycin (single dose) or
ducreyi) with ragged edges. Inguinal nodes culture, PCR. IM ceftriaxone (single dose)
enlarge, become tender, may
suppurate.
Granuloma Inguinale Painless red nodule which develops Clinically. Giemsa/Wright Doxycycline or TMP/SMZ.
(Donovania granulomatis into an elevated granulomatous stain shows intracellular Erythromycin can be used as
/Klebsiella granulomatis) mass. Healing is slow with scar inclusion (Donovan bodies). an alternative.
formation Punch biopsy.
Genital herpes (Herpes Vesicle on skin and mucous membrane Tzanck smear, culture. Acyclovir for 7-10 days in
type II) (anogenital area), which erode and primary infection, or
become painful. Presents as circular valacyclovir. Sexual contacts
ulcer which scar. Tender inguinal lymph- to be examined.
adenopathy. Disease may have
relapsing course.
Genital warts Soft, minute, pink, or red swelling. Clinically. Curettage, trichloroacetic
(Papilloma virus) Grows rapidly and attains cauliflower acid, podophyllin, Imiquimod,
shape (Diagnosis clincher) cryotherapy.
Treatment
Diagnosis
Antibiotics of choice are TMP-SMX or fluoroquinolones
An important clue to development of perinephric abscess for 14 days. In chronic prostatitis extend the treatment to 1
may be persistence of pyelonephritis symptoms despite month with fluoroquinolones and up to 3 months with
treatment. Either a negative urine culture with pyuria and TMP-SMX.
fever or positive polymicrobial culture in absence of 99er-Presumptive prostatitis should be evaluated with
symptoms is highly suggestive. Ultrasound is required to urinalysis and urine culture.
detect the extent of abscess. CT/MRI offer better imaging Non-bacterial prostatitis is a common non-infectious
than ultrasound, but may not be preferred in this condition inflammatory disorder where patient presents with history
of pain and > 20 leukocytes/hpf but culture is negative.
because of high cost and not much extra diagnostic benefit.
Treatment involves symptomatic management with Sitz
bath and NSAIDs.
Treatment
The mainstay of treatment for perinephric abscess is BONE AND JOINT INFECTION
drainage. Antibiotics mainly are used as an adjunct to Osteomyelitis
percutaneous drainage because they help to control sepsis
It is an acute or chronic inflammatory process of the bone
and prevent the spread of infection. An antistaphy-
and its structures (marrow, cortex, and periosteum)
lococcal beta-lactam agent (nafcillin, cefazolin) and an
secondary to infection with pyogenic organisms. It can be
aminoglycoside (gentamicin), or ticarcillin/clavulanate
classified into two types:
are appropriate choices for the initial treatment. After the Hematogenous osteomyelitis: It is caused by bacterial
culture report, the antibiotics can be adjusted accordingly. seeding from the blood, carried from a remote source
99er Abscess- whenever a patient continues to have and is secondary to a single organism most of the time
fever despite use of adequate antimicrobial coverage over (S. aureus most common). This condition occurs
an adequate time frame, abscess should be considered as primarily in children. The most common site is the
a potential cause. And though this might be contrary to rapidly growing and highly vascular metaphysis of
the fact mentioned above, some literature indicates CT scan growing bones.
of abdomen as the next step to be taken, if abscess is Direct or contiguous inoculation osteomyelitis: It is
suspected clinically. caused by direct contact of the tissue with bacteria
during trauma or surgery. Clinical manifestations of
direct inoculation osteomyelitis are more localized
Prostatitis
than those of hematogenous osteomyelitis and tend to
It is acute infection of prostate gland. involve multiple org anisms (S. aureus still most
common).
Clinical Features 99er-Diabetes and PVDAnother form of
osteomyelitis which is typically seen in diabetic or patient
Patient presents with spiking fever, chills, dysuria, cloudy suffering from peripheral vascular disease, is due to
urine, and may be obstructive symptoms if prostate has vascular insufficiency. These patients often get repeated
significant swelling. Patients who have chronic infection minor trauma (which goes unnoticed due to neuropathy)
may present with perineal or testicular discomfort along most commonly in small bones of the lower extremities.
with low back pain. On digital rectal examination (DRE), Often there is an obvious overlying or nearby ulceration or
prostate is very tender. Chronic prostatitis presents either wound. Its a polymicrobial infection with S. aureus still
with lower UTI and tenderness or is asymptomatic. being most common pathogen.
Infectious Diseases 33
are at greater risk during menses and pregnancy and are Clinical Features
2-3 times more likely than men to develop disseminated
The incubation period is usually less than 24 hours and
arthritis.
when symptoms start, clinical deterioration can occur
Group B streptococcimost commonly infects the within hours. Muscle swelling and severe pain are
sacroiliac and sternoclavicular joints. prominent features (diagnosis clincher). The pain is often
GonococcalJoint involvement is polyarticular in majority out of proportion to physical findings, reflective of the
and commonly is migratory in nature. Tenosynovitis is hypoxic state of the muscle tissue, and is a key to
much more common and effusions less common as distinguishing gas gangrene from simple cellulitis. Later
compared to nongonococcal. Skin manifestations with hypotension, tachycardia, and fever can occur, which is
followed by crepitation at wound site and renal failure.
petechiae or purpura are common, but seldom number
more than 12.
Diagnosis
99er-Septic bursitis- most commonly involves the
olecranon and prepatellar bursae. Swelling and pain are Gram stain and culture of bullae fluid shows Gram-positive
present, but an infected bursa does not limit the range of rods. Culture is not diagnostic. Direct visualization with
motion of the underlying joint the way an actual joint relevant history is more diagnostic. X-ray may show gas
infection does. bubbles in wound.
Diagnosis Treatment
Gas gangrene is a true emergency and the treatment is a
Nongonococcal: Joint aspirate fluid shows cell count
combination of antibiotics, surgery, and hyperbaric
> 50,000, which is predominantly PMNs with low glucose.
oxygen. High-dose penicillin (24 million/day) or
Gram stain is positive in majority. Joint fluid is culture clindamycin (if penicillin allergic) is necessary, but
positive in almost all patients. surgical debridement or amputation is the mainstay of
Gonococcal: It is harder to culture. Only 50% of joint treatment.
aspirates have positive synovial fluid culture. Other sites
such as cervix, pharynx, rectum, and urethra may also be CARDITIS
positive.
Infective Endocarditis (IE)
Treatment It is an infection of the endocardial surface of the heart
leading to colonization of heart valves causing valve injury
Medical management of infective arthritis focuses on
and development of friable infected vegetations. Left side
adequate and timely drainage of the infected synovial fluid,
is more commonly involved. Bacterial endocarditis
administration of appropriate antimicrobial therapy, and
produces large vegetations and may affect any value in
immobilization of the joint to control pain. Antibiotic to be the heart. There are various pathologies in heart that
given should depend on the likely etiology. predispose it to IE. The most significant risk factor for IE is
Nongonococcal: Nafcillin or oxacillin combined with an residual valvular damage caused by a previous attack of
aminoglycoside or a third generation cephalosporin is endocarditis. Others are:
good empiric therapy. Prosthetic valve
Gonococcal: Ceftriaxone is drug of choice. Mitral regurgitation
Aortic valve disease
Gas Gangrene Patent ductus arteriosus
Coarctation of aorta
It is a subset of necrotizing myositis and an infectious
AV fistula
disease emergency caused by gas producing Clostridium Intracardiac indwelling catheters
perfringens. It is strongly associated with traumatic injury, Marfan syndrome
motor vehicle injury, or shrapnel injury in war. The wound Few common procedures that predispose to IE are:
that usually develops gas gangrene is deep, necrotic, and Endoscopy
without exit to the surface. Colonoscopy
Infectious Diseases 35
According to Dukes criteria IE is diagnosed with either pericarditis), mediastinum irradiation, cardiac trauma or
two major or one major and three minor. surgery, MI associated, Dressler syndrome, neoplasm, drug
associated (penicillin), etc.
Treatment
Clinical Features
Empiric therapy can be started if there is clear evidence of
IE due to typical presentations or the patient is too ill to Chest pain is the cardinal symptom, which may be
wait for culture reports. Preferable empiric therapy include sharp, dull, aching, burning, or pressing and is
antistaphylococcal drug such as naficillin, a streptococcal precordial in location. It is worse during inspiration,
drug such as penicillin/ampicillin, and gentamicin. when lying flat, or during swallowing and with body
Strep. viridans: Penicillin is preferred drug. Ceftriaxone motion. It typically gets relieved by bending forward
or vancomycin is given in penicillin allergic patients. (Diagnosis clincher).
Dyspnea may be present, especially with tamponade.
Staph. aureus (native valve): Nafcillin plus 5 days of
Fever may be present.
methicillin (if methicillin sensitive).Vancomycin in case
A pericardial friction rub is pathognomonic for acute
of MRSA. In case of prosthetic valve infection, Nafcillin
pericarditis and has a scratching, grating sound
(or vancomycin in allergic patients) plus gentamicin is
similar to leather rubbing against leather.
therapy of choice.
Tachypnea and tachycardia may be present.
Indications for surgery are:
If patient develops tamponade, the Beck triad
Congestive heart failure refractory to standard medical
(hypotension with elevated systemic venous pressure,
therapy
often with jugular venous distention and muffled heart
Fungal IE (except that caused by Histoplasma
sounds) may occur in patients. Pulsus paradoxus,
capsulatum)
defined as a > 10 mm Hg decrease in arterial systolic
Persistent sepsis after 72 hours of appropriate
pressure with inspiration, is also seen.
antibiotic treatment
Recurrent septic emboli, especially after 2 weeks of
Diagnosis
antibiotic treatment
Rupture of an aneurysm of the sinus of Valsalva Chest X-ray: Flask-shaped enlarged cardiac silhouette if
Conduction disturbances caused by a septal abscess large pericardial effusion is present.
Kissing infection of the anterior mitral leaflet in patients EKG: ST segment elevation in almost every lead, except
with IE of the aortic valve aVR. The ST elevation progresses to T-wave inversion. PR
Prophylaxis against IE: Prophylactics are indicated in depression may occur. Electrical alternans, if effusion is
patients with already underlying cardiac predispositions, so large that the heart swings in it.
who are undergoing procedure that predispose a patient Echo: It is recommended in all cases to detect an effusion.
to IE. Patient undergoing dental procedure should be
Pericardiocentesis: To examine fluid for possible
given amoxicillin. For penicillin-allergic patients
underlying etiology.
clindamycin or azithromycin, or clarithromycin are good
choice. Patients undergoing urinary or gastrointestinal
Treatment
procedures need to be given ampicillin and gentamicin.
Vancomycin and gentamicin is good choice for penicillin Viral endocarditis is treated with NSIADs like
allergic patients. indomethacin, or ibuprofen. Prednisone is used if there is
no response. Large Pericardiocentesis and pericardial
Acute Pericarditis window placement are required in case of massive
effusion.
It is an inflammation of the pericardium caused due to
virtually any infectious agent. Viral infection is the most
Myocarditis
common cause (coxsackie being most common). It is so
common that even idiopathic causes are now thought to It is collection of diseases of infectious, toxic, and
be undiagnosed viral cases. Other causes include bacterial, autoimmune etiologies characterized by inflammation of
tubercular, RA, SLE, scleroderma, renal failure (uremia), the heart. Myocarditis is caused by the same etiological
hypothyroidism, cholesterol pericarditis (gold-paint factors mentioned in pericarditis.
Infectious Diseases 37
AIDS is defined as CD4 count <200. At this time patient 99er - IV pentamidine- is associated with a number of
develops many opportunistic infections which are metabolic and electrolyte disturbances including hypo/
characteristic of development of AIDS. hyperkalemia, hypo/hyperglycemia (use finger stick blood
99er - Disseminated cryptococcal neoformans test for detection), hypocalcemia.
infection- Presents usually as meningitis and encephalitis. Tests for knowing disease status include CD4
Most common extraneural manifestation is skin count and viral load.
involvement which shows as multiple, discrete flesh to CD4 cell count: It is the most accurate method of
red color papules of varying sizes with slight central determining what infections or diseases the patient is at
umbilication. Skin involvement is diagnosed by biopsy of risk of and when to start prophylactic treatment against
lesion (PAS and gomori methamine silver stain required). them. It is an indicator of current immunity level of the
If skin involvement by Cryptococcus is confirmed, its patient. It is also an indicator of when to start antiretroviral
manadatory to go for chest X-Ray, blood and CSF culture, medication (when CD4 <350). Without treatment, the CD4
india ink stain of CSF and cryptococcal antigen detection count drops 50-75 cells per year. CD4 count also gives an
in CSF and blood. idea of adequacy of response to medication.
Pneumocystis Dyspnea on minimal exertion (dia-Bronchoscopy with broncho- TMP/SMZ (1st choice), Pentamidine.
carinii gnosis clincher), dry cough, fever, alveolar lavage for direct identi- Prednisone in severe pneumonia. For
pneumonia, chest pain. Severe fication of the organism prophylaxis: oral TMP/SMZ,
pneumonia is defined with a PO2 (confirmatory). LDH is increased. aerosolized pentamidine, dapsone,
of <70 or an A-a gradient of >35. atovaquone.
Toxoplasmosis Brain mass lesion: focal neurolo- CT or MRI:ring (contrast) enha- Pyrimethamine and sulfadiazine
gical deficits, headache, ncing lesion with edema, and (clindamycin in sulfa-allergic patient).
confusion, seizures. mass effect. Drug trial: Shrink- Prophylaxis: TMP/SMZ,Dapsone/
age of the lesions upon giving pyrimethamine.
therapy for two weeks is consi-
dered diagnostic.Brain biopsy:
if no lesion shrinkage with
treatment.
Mycobacterium- Fevers bacteremia, wasting, Culture blood; liver, bone Clarithromycin and ethambutol.
avium complex anemia. marrow biopsy Prophylaxis: azithromycin once a
(MAC) week/ Clarithromycin twice a day/
Rifabutin
Cytomegalovirus Retinitis: blurry/double vision. Funduscopy, coloscopy with Ganciclovir foscarnet, cidofovir
Diarrhea due to colitis. biopsy.
Cryptococcosis Meningitis LP with India ink test and crypto- IV Amphotericin (10-14 days). Lifelong
coccal antigen testing. Markedly fluconazole.
elevated pressure on LP.*Serum
cryptococcal antigen testing.
Prophylactic drugs can be stopped if the CD4 count is Also all HIV-positive persons should receive vaccinations
maintained above the disease causing level for 3-6 months. for pneumococcus, influenza, and hepatitis B.
Infectious Diseases 39
Table 2.13: CD4 count and associated diseases count, it also tells when to initiate antiretroviral
medications and about the adequacy of response to
CD4 count Disease medications. The antiretroviral therapy is initiated when
700-1500 Normal viral load > 55,000 and its goal is a viral load <400.
200-500 Kaposi sarcoma, thrush, shingles,
lymphoma, TB
Table 2.14: Antiretroviral drugs and adverse effects
100-200 Dementia, Pneumocystis carinii
pneumonia (PCP) Drug class Drugsadverse effects
<100 Cryptococcus, toxoplasmosis,
cryptosporidiosis Protease inhibitors
<50 MAC, CMV, progressive multifocal Hyperlipidemia, hyperglycemia, and
leukoencephalopathy (PML) elevated liver enzymes seen in all drugs
of the class
Nelfinavir-Gastrointestinal
99er-HyponatremiaIn hospitalized AIDS patient
Indinavir-Crystal induced nephrolithiasis,
is seen in 50% of cases. There are many reasons for it, like hyperbilirubinemia
various drugs administered, CMV or mycobacteria Ritonavir-Severe gastrointestinal
adrenalitis, CNS involvement causing SIADH etc. If no disturbance
specific cause is found out, fluid restriction is used for SaquinavirGastrointestinal
mild cases.
Nucleoside reverse
99er-Progressive multifocal leukoencephalopathy transcriptase All can cause lactic acidosis
(PML)-is an infection caused by JC virus and involves inhibitors Zidovudine-Leucopenia, anemia,
mainly cortical white matter but brainstem and cerebellum gastrointestinal disturbance
may also be involved. No mass effect or increased ICP is Didanosine-Pancreatitis, peripheral
seen. It presents with rapidly progressive focal neurological neuropathy
deficits along with hemiparesis, disturbance of speech, Zalcitabine -Pancreatitis, peripheral
neuropathy
gait and vision. MRI is best diagnostic test which shows
Stavudine-Peripheral neuropathy
multiple demyelinating non enhancing lesions. Biopsy Lamivudine: not known yet
shows oligodendrocytes with intranuclear inclusions, Abacavir- Hypersensitivity, rash
demyelination and astrogliosis. No specific treatment is
required. Non-nucleoside All can cause Steven Johnson syndrome.
reverse Efavirenz-neurologic; somnolence,
99er-HIV and persistent diarrhea- may be because of
transcriptase confusion, or psychiatric disturbance,
Cryptosporidium or Isospora. Fresh stool examination with inhibitors teratogen (animal studies)
a modified acid fast stain should be done to find out these Nevirapine-Rash
parasites. Diarrhea due to Isosporais is responsive to
treatment by 1-week course of trimethoprim Highly active antiretroviral therapy, HAART
sulfamethoxazole.
99er-Primary CNS lymphoma (PCNSL) - is caused HAART is indicated when:
by EBV in AIDS. HAART therapy improves prognosis
There is history of AIDS defining illness
because degree of immunosuppression is major
determinant of survival in PCNSL. Severe symptoms of HIV infection
Asymptomatic patient with CD4 <200.
Viral Load
Pregnant women
High viral loads generally indicate that the level ofCD4
cells are going to drop more rapidly and that there is a If symptomatic, but CD4 count is between 201-350 than
greater risk of complications of the disease and a worse discuss risk and benefit of HAART. Asymptomatic with
prognosis. Hence, it is marker of potential for future damage CD4 count > 350 and viral load <10000, defer HAART.
to immune system, i.e. damage that is about to occur. Patient with very high viral count or rapidly declining
Therefore, it carries prognostic significance. Like CD4 CD4 count (> 100/year) should start HAART therapy.
40 The Definitive Review of Medicine for USMLE
99er-Catheter induced infection- Femoral sites are at 99er-Cervicofacial actinomycosis- presents as slowly
greatest risk. Site of insertion shows redness/induration progressive, non-tender, indurated mass, which evolves
with/without drainage. Two set of blood cultures should into multiple abscesses, fistula, and draining sinus tracts
be drawn, preferably through tunneled catheter. Treat by with sulfur granules (appear yellow). Actinomyces israelii
immediate catheter removal and give vancomycin plus is the causative agent. Treatment is high dose IV penicillin
gentamicin. for 6-12 weeks. Surgical debridement may be required after
99er-Invasive aspergillus- is common in bone marrow penicillin therapy.
transplant patient. It involves respiratory tract including 99er-Anthrax- caused by Bacillus anthracis and is a
lungs and sinuses. disease of cattle and sheep etc, but it can be transmitted to
99er-Fever of unknown origin (FUO) is a tempera- humans through broken skin or mucous membrane,
ture greater than 38.3C (101F) on several occasions, for inhalation (usually fatal and most common form used in
more than 3 weeks duration of illness, and the failure to biological warfare), and GI absorption. It usually manifests
reach a diagnosis despite 1 week of inpatient investigation. as cutaneous lesions-necrotic but not purulent (malignant
Most commonly it is due to some infectious condition. pustule) and black eschar (diagnosis clincher); inhalational-
biphasic, initially malaise, myalgia, fever cough and
99er-Rocky mountain spotted fever (RMSF) - typically
second phase lasting 24 hours (and culminating into
starts 3-5 days after tick bite. Rash typically begins around
death) characterized by respiratory distress, hypoxemia
the wrists and ankles, but it may start on the trunk or be
and cyanosis. GI infection is rare. Treatment is by
diffuse at the onset. The classic distribution of RMSF rash
ciprofloxacin or doxycycline. Amoxicillin is used in
on the palms and soles occurs relatively late in the course
children and women who are pregnant or breastfeeding.
(in majority around 5th day). Diagnosis and treatment (by
99er-Sporotrichosis- is caused by saprophytic fungi
doxycycline) is done on basis of clinical presentation and
Sporotrichosis schenckii, present on rose, barberry,
is done empirically without waiting for diagnostic
sphagnum etc. It is characterized by exposure to plants,
confirmation.
gardens, or forests; chain of lesion typically at the site
99er-In any pyretic infection, if possible, blood culture
where the fungus is introduced by some minor trauma
should be taken 1 hour before the spike of temperature.
(diagnosis clincher), and absence of systemic symptoms.
99er-Rabies- previously vaccinated patients, upon Localized lymphadenopathy may be seen as subcutaneous
reexposure should receive vaccine only. Patients, not nodules. Treatment is by oral itraconazole.
exposed earlier should be given both vaccine and IgG. 99er-Spontaneous bacterial peritonitis: is diagnosed
99er- Diphtheria antitoxin- made from horse serum when >250 neutrophils/mm3 are present in peritoneal
can cause hypersensitivity or serum sickness. fluid.
99er-Candida endophthalmitisrisk factors include 99er-Salmonellosis- no treatment is required except
CNS catheterization, total parenteral nutrition, broad when < 12 months of age, >50 years of age, or
spectrum antibiotic, neutropenia, steroids, IVDA. It immunocompromised. Treatment is ciprofloxacin/TMP-
presents as ocular pain, photophobia, scotoma, fever. SMX.
Treatment involves vitrectomy followed by systemic 99er-Malaria- typically present in patient with travel
amphotericin B. to endemic areas and a typical pattern of febrile attacks. It
Infectious Diseases 43
is caused by Plasmodium infection, which is detected in 99er-Human bites- contains hemolytic strepto-
peripheral slide smears. Thick blood film preparations are coccus, S. aureus, eikenalla (commonly found in soft tissue
helpful in parasite detection and thin films help to infection after bite), haemophillus, and anaerobic
differentiate different plasmodium species. These organisms. HIV is not transmitted by human saliva.
peripheral smears should be examined every 8 hours during
Amoxicillin/clavulunate is drug of choice.
and between febrile attacks for at least 3 days.
99er-Dog/cat bite: Pasturella multocida is commonly
99er-Cysticercosis- is caused by ingestion of Tenia
solium eggs in undercooked pork. Brain is a preferred site found. Wound infection may be complicated by
of lodging and it presents with nausea and vomiting, osteomyelitis. Treatment is same as for human bites.
seizure, chronic headache etc. Serology is most useful lab 99er-Animal bites- treatment involves local wound
test. CT scan is recommended as the first imaging study. management, rabies prophylaxis, tetanus prophylaxis and
Antihelminthic agents like praziquantel and albendazole the usual antibiotics. Also animal involved in bites should
are the mainstay of treatment. be kept under observation for 10 days to look for alarming
99er-Trypanosomiasis- causes Chagas disease, symptoms in animal. Till than no treatment is required. If
which is endemic in South America. It is caused due to alarming symptoms are present or it becomes ill, the animal
person to person transmission by trympanosoma cruzi,
may be sacrificed and the brain be tested for rabies by
an intracellular protozoon that localizes in heart and nerve
immunofluorescent antibody test. Treatment is indicated
cells of myenteric plexus and causes myocarditis, achlasia,
megacolon, and megaureter. Benznidazole is the only when the test is positive or the animal was wild. It involves
treatment for Chagas disease, though its still not available active (human diploid cell vaccine) and passive (human
in US. Surgery may also be indicated for few complications. rabies immune globulin) immunization.
Chapter
3 Rheumatology
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) including interstitial nephritis and membranous GN.
All patients with renal involvement must undergo
It is a chronic, multifaceted inflammatory disease that can
renal biopsy before treatment is initiated. Renal
affect every organ system of the body and is associated
involvement is the most common cause of death.
with antibodies directed against cell nuclei. It is majority
Antinuclear antibodies (ANAs) Is highly sensitive
of times seen in women and only environmental agent
and higher titers are generally more specific (>1:160).
that is reliably known to affect it is UV-B (causes flare-
Its measurement is screening test of choice.
ups). It may sometimes occur secondary to drug use (like
Immunologic phenomena Lupus erythematosus
procainamide, hydralazine, and pencillamine) and is
(LE) cells, antidouble-stranded DNA (dsDNA), anti-
reversible in this case.
Smith (Sm) antibodies, antiphospholipid antibodies
[anticardiolipin immunoglobulin G (IgG) or
Clinical Features
immunoglobulin M (IgM) or lupus anticoagulant].
Its presentation and course is highly variable, ranging from False-positive serologic test results may be seen with
indolent to fulminant. Nonspecific fatigue, fever, arthralgia syphilis.
and weight changes are the most frequent symptoms in Neurologic disorder CNS symptoms may range from
new cases or recurrent active SLE flares. Arthralgia, mild cognitive dysfunction to a history of seizures
myalgia, and arthritis represent the most common (grand mal most common). Any region of the brain,
presenting symptoms in SLE. Libman-Sacks endocarditis Meninges, spinal cord, and cranial or peripheral nerves
is a noninfectious endocarditis that may be rarely can be involved. Intractable headaches and difficulties
encountered in a lupus patient. with memory and reasoning are the most common
features of neurologic disease in patients with lupus.
Diagnosis Mononeuritis manifests with the functional loss of one
The ACR diagnostic criteria in SLE (in SOAP BRAIN MD or a few isolated peripheral nerves.
acronym). Diagnostic criteria need four out of the following Malar rash Erythematous rash over the cheeks and
to diagnose. nasal bridge that lasts from days to weeks and is
Serositis Pleurisy, pericarditis. occasionally painful or pruritic.
Oral ulcers Oral or nasopharyngeal, usually Discoid rash Develop in sun-exposed areas but are
painless; palate is most specific. plaquelike lesions with follicular plugging and
Arthritis Small joints of the hands, wrists, and knees scarring. They may be part of systemic lupus or may
are involved most frequently. Pain is often out of represent discoid lupus without organ involvement,
proportion with swelling. which is a separate diagnostic entity.
Photosensitivity Unusual skin reaction to light 99er-Positive ANAs in absence of SLE symptoms,
exposure. doesnt carry any meaning and therefore no further testing
Blood disorders Leukopenia, lymphopenia, is required.
thrombocytopenia, and Coombs testpositive anemia. 99er-Active SLE flare-up is characterized by decreased
Renal involvement Proteinuria (>0.5 g/d or positive C3 and C4 level and elevated ESR and CRP levels.
on dipstick testing; cellular casts). It often causes The following are autoantibody tests used in SLE
nephrotic syndrome (sometimes nephritic syndrome diagnosis:
also) and may progress rapidly to renal failure. It causes ANAScreening test; sensitivity 95%; not diagnostic
various disorders of the internal structures of the kidney, without clinical features.
Rheumatology 45
Anti-dsDNAHigh specificity; sensitivity only 70%; be used safely during pregnancy and should not be
level variable based on disease activity. Elevated levels discontinued since this could lead to disease flares.
seen with active SLE and lupus nephritis. 99er-Lifelong anticoagulation with warfarin is
Anti-SmMost specific antibody for SLE; only 30-40% required in SLE patients who have antiphospholipid
sensitivity. antibody syndrome.
Anti-SSA (Ro) or Anti-SSB (La)Present in 15% of
patients with SLE and other connective tissue diseases SYSTEMIC SCLEROSIS
such as Sjgren syndrome; associated with neonatal
lupus and congenital heart block. The term systemic sclerosis is used to describe a systemic
Anti-ribosomal PUncommon antibodies that may disease characterized by skin induration and thickening
accompanied by various degrees of tissue fibrosis and
correlate with lupus cerebritis.
chronic inflammatory infiltration in numerous visceral
Anti-RNPIncluded with anti-Sm, SSA, and SSB in
organs.
the ENA profile; may indicate mixed connective tissue
disease with overlap SLE, scleroderma, and myositis.
Clinical Features
Anti-histoneseen in drug-induced lupus (DIL) (with
isoniazid, procainamide or hydralazine; p-ANCA Constitutional
positive in minocycline-induced DIL). This is usually Fatigue
a limited form of lupus with no major organ Weight loss.
involvement or hypocomplementemia. Apart from anti- Skin
histone antibodies, it may present only with a rash Diffuse pruritus
and resolves with removal of offending drug. Skin tightness and induration
99er-Monitoring SLE disease activity can be done by Skin pigmentary changes (hyperpigmentation or
measuring serum complement levels and dsDNA hypopigmentation- salt and pepper distribution).
antibody. Vascular system
99er-Mixed connective tissue disease- diagnosed Raynauds phenomenon (70% of patients initially
when positive anti-RNP along with 3 clinical features of present with this symptom; 95% eventually develop
SLE, polymyositis, systemic sclerosis are present. it during the course of their disease)
Healed pitting ulcers in fingertips
Treatment Cutaneous and mucosal telangiectasias.
Musculoskeletal system
Arthritis and mild serositis are treated with NSAIDs. Arthralgia, myalgia, muscular weakness
Arthritis not responsive to NSAIDs can be treated by Loss in joint range of motion
Hydroxychloroquine, which is also effective in treatment Symptoms of carpal tunnel syndrome.
of rashes. Widespread systemic involvement requires Neurologic
steroids and immunosuppressants treatment. Steroids are Facial pain and hand paresthesias due to sensory
also used to treat patients undergoing flare-up reaction. peripheral entrapment neuropathy
Headache and stroke during hypertensive renal
Pregnancy and SLE: Fertility rates are normal in patients
crisis.
with SLE, but spontaneous abortions and stillbirths are
Ears, nose, and throat
more common (due to anti-phospholipids antibodies, Sicca syndrome
which cause placental infarcts). They also need to be Poor dentition due to sicca syndrome
screened for SSA/anti-Ro antibodies which may cause Loosening of dentition due to alteration in the tooth
neonatal lupus and rarely permanent heart block. suspensory ligament and thickening of the
Although disease flares can occur in pregnancy, they periodontal membrane
arent typically more frequent or more intense than those Hoarseness due to acid reflux or vocal cord fibrosis.
seen in non-pregnant patients and can be safely treated Cardiovascular system
with prednisone, prednisolone, and methylprednisolone, Dyspnea due to pericardial effusion, congestive
the corticosteroids of choice because they are only heart failure, or myocardial fibrosis
minimally transferred to the placental circulation. High Palpitations, irregular heartbeats, and syncope due
doses of aspirin and NSAIDs should be avoided during to conduction abnormalities
the last few weeks of pregnancy. Hydroxychloroquine can Congestive heart failure.
46 The Definitive Review of Medicine for USMLE
part from the history and physical examination. Laboratory Symmetrical/non-symmetrical involvement
test results may confirm clinical impressions. The points Nature of disease: Inflammatory or non- inflammatory.
to be kept in mind while dealing with question involving
joint diseases are: RHEUMATOID ARTHRITIS (RA)
Course of disease: Acute or chronic It is a chronic systemic inflammatory disease of
Joint involvement: Monoarticular or polyarticular undetermined etiology involving primarily the synovial
membranes and articular structures of multiple joints. The portion becomes trapped and separated from the rest
hallmark feature of the disease is persistent symmetric of the joint, forming a Baker cyst. It often occurs fairly
polyarthritis (synovitis) that has potential to destroy early in the course of the disease, with pain, edema,
cartilage and cause bone erosions and eventually deform and inflammation in the posterior knee and calf.
the joint. RA seems to be associated with cigarette smoking. Cardiac involvement: Carditis, pericarditis.
T cells play the main role in pathogenesis and any disease Pulmonary involvement: Pleuritis, intrapulmonary
or drug that negatively affects them may help relieve the nodules, interstitial fibrosis (Caplans syndrome).
symptoms of RA. Hepatic involvement: Hepatitis.
Juvenile rheumatoid arthritis (JRA) is the most common Ocular involvement: Scleritis, episcleritis, dryness of
form of childhood arthritis. The cause remains unknown. the eyes (Keratoconjunctivitis siccain 25% of RA
patients).
Clinical Features Vascular involvement: Vasculitis (rheumatoid nodule).
Stiffness of joint and pain are the chief problems with Neurological: Entrapment neuropathy (carpal tunnel
which patient presents initially. He may also complain of syndrome) may result from synovitis about the flexor
constitutional symptoms like fatigue, malaise, and weight tendons. It is evinced by pain and/or paresthesias in
loss. RA typically involves small joints of hand. the median nerve distribution of the hand, a positive
Atlantoaxial subluxation may present with occipital Phalen and/or positive Tinel test, or positive
headaches. electromyography. Radiculopathy is most common at
Sometimes patient may present when joint deformity the C2 root when cervical spine is involved.
is already visible. Long standing RA is one of the most 99er-Parvovirus infection: RA like symptoms with
common causes of amyloidosis. Various other features of small joint involvement and weakly RF positive.
RA that are caused due to extra-articular and systemic
involvement are: Diagnosis
Damage to the ligaments and tendons: This leads to
The diagnosis is based on the use of clinical criteria; there
severe deformity of joints.
is no single test or finding that will diagnose RA. The
Zig-zag deformity: Combination of an ulnar drift
diagnosis typically is made when 4 of 7 qualifying criteria
of the fingers and carpal rotation. Radial deviation
established by the American Rheumatism Association are
of the wrist with ulnar deviation of the digits.
met. These qualifying criteria are as follows:
Boutonniere deformity: Nonreducible flexion at the
proximal interphalangeal (PIP) joint along with Morning stiffness lasting longer than 1 hour before
hyperextension of the distal interphalangeal (DIP) improvement
joint of the finger. Arthritis involving 3 or more joints.
Swan-neck deformity: Hyperextension at the PIP joint Arthritis of the hand, particularly involvement of the
with flexion of the DIP joint. proximal interphalangeal (PIP) joints, metacarpo-
Arthritis mutilans (opera glass hands): If destruction phalangeal (MCP) joints, or wrist joints.
is severe and extensive, with dissolution of bone. Bilateral involvement of joint areas.
Phalanges may shorten and the joints may become Positive serum rheumatoid factor (RF).
grossly unstable. Pulling on the fingers during Rheumatoid nodules.
examination may lengthen the digit much like Radiographic evidence of RA (periarticular
opening opera glasses, or the joint may bend in osteoporosis with erosions around affected joints).
unusual directions merely under the pull of gravity. The diagnostic criteria for JRA are onset occurring
Rheumatoid nodules: They are most commonly found when younger than 16 years, persistent arthritis in one or
on extensor surfaces or sites of frequent mechanical more joints for at least 6 weeks, and exclusion of other
irritation (olecranon process, back of heel, Achilles types of childhood arthritis.
tendon). It is initial event caused by focal vasculitis.
Methotrexate may flare this process. Treatment
Bakers cyst: When the effusion of a joint is put under RA flares or exacerbations (increased pain, edema, and
increased pressure with joint flexion, the synovium dysfunction, high titers of RF) require rest, NSAIDs,
may be forced between articular structures and a DMARDs, short courses of prednisone (2-4 wk), and
Rheumatology 49
possibly intra-articular steroid injections. DMARDs are cartilage of synovial joints, particularly large weight-
indicated in erosive RA and also those who are steroid bearing joints (hip and knee). OA is a non-inflammatory
dependent. Methotrexate is initial DMARD of choice. disease, particularly common in older patients. OA can
Patients presenting with mild RA are treated initially with develop secondary to various causes like:
NSAIDs, upon which hydroxychloroquine may be added Obesity (increased mechanical stress)
if NSAIDs are not effective alone. Moderate to severe cases Repetitive use
are treated with NSAIDs and methotrexate. If methotrexate Previous trauma (post-traumatic OA)
fails or is contraindicated, than anti-TNF drugs like Infection
Infliximab, etanercept, etc. are used. Gold and Crystal deposition
immunosuppressants are the last resort if nothing works. Acromegaly
In RA patients with atlantoaxial subluxation (C1-C2). Neuropathic disorder leading to a Charcot joint
any hyperextension of the neck may cause permanent (syringomyelia, tabes dorsalis, diabetes)
damage to the spinal cord. Therefore RA patients before Previous rheumatoid arthritis (burnt-out rheumatoid
anesthesia or intubation must be screened for this with a arthritis)
plain X-ray (lateral neck and open mouth views). If there Heritable metabolic causes (alkaptonuria, hemochro-
is evidence of subluxation, then stabilize the spine before matosis, Wilson disease)
the procedure. Hemoglobinopathies (sickle cell disease, thalassemia)
99er- Steroid therapygive vitamin D3 and Ca2+ to
Underlying orthopedic disorders (congenital hip
prevent osteoporosis and do bone densitometry every year.
dislocation, slipped femoral capital epiphysis).
Felty syndrome: A triad of RA, neutropenia, and
The most common joint to be affected is the knee. It is
splenomegaly. Patients are prone to serious bacterial
the leading cause of chronic disability in the elderly in the
infections and this requires prompt diagnosis and
western world. The second most common site for OA is
initiation of antibiotic therapy.
the thumb base.
Ruptured Baker cysts are often confused with deep
vein thrombosis (DVT). The diagnosis is best made with
Clinical Features
ultrasonography. Treatment includes rest, elevation, needle
puncture of the calf, knee joint aspiration, and referral. Deep, achy, joint pain exacerbated by extensive use and
Carpal tunnel syndrome treatment includes rest, relieved by rest is the primary symptom. Also, reduced
temporary immobilization, NSAIDs, and surgery. range of motion and crepitus are frequently present. Joint
99er-Carpal tunnel syndromeSuspected when malalignment may be visible. Heberden nodes, which
patient complains of pain/paresthesia when wrist joint is represent palpable osteophytes in the DIP are characteristic
compressed and this is also the first step of diagnosis. in women but not in men. They are known as Bouchards
Tinel test (pain/paresthesia upon tapping radial nerve) nodes when they are in PIP. Major joints involved in OA
and phalen maneuver (pain/paresthesia after 30-60 wrist are hip, knee, and the small joints of the fingers (PIPs and
flexions) are positive. Electrodiagnostic tests are DIPs). The joint involvement is very slow, progressive, and
confirmatory diagnostic modality. Most effective initial irreversible. Morning stiffness is always < 20-30 min.
treatment is night time wrist splinting.
99er-Adult Stills disease is a variant of rheumatoid Diagnosis
arthritis which is seen in 20-30s age groups. Patient has No laboratory studies can assist in diagnosis of OA per se.
high spiking fever, evanescent salmon color macular rash All indices of inflammation like ESR are normal. Diagnosis
on trunks or extremity. Patient also has arthritis, arthralgia is made on clinical and X-Ray findings.
and leukocytosis. RF and ANA are negative. Liver failure X-ray: It shows osteophytes, subchondral sclerosis,
is a serious problem in Stills disease patient who are taking and unequal and narrowed joint space.
NSAIDs. Therefore, LFTs should be monitored. NSAIDs,
glucocorticoids and Methotrexate are the drugs used for Treatment
treatment.
Physical Therapy
OSTEOARTHRITIS (OA)
Lifestyle modification, particularly exercise and weight
Also known as degenerative arthritis, it is the most common reduction is a core component of the management of OA.
joint disease which is a chronic process affecting articular Correction of poor posture also helps.
50 The Definitive Review of Medicine for USMLE
can wait and start if there is second attack. Probenecid Ankylosing Spondylitis
is used in the undersecretors (>80% of adults).
It is a chronic, painful, degenerative inflammatory arthritis
Allopurinol is used in overproducers or patients with
renal failure or kidney stones. primarily affecting spine and sacroiliac joints, causing
99er-Allopurinol and probenecid therapy shouldnt eventual fusion of the spine. It is more common in man
be started during/ after acute gout attacks. and starts usually in second to third decade of life.
Pseudogout is inflammation caused by calcium Morning stiffness is characteristic, and fatigue is common.
pyrophosphate (CPP) crystals and is sometimes referred It usually presents with chronic lower back pain in a young
to as calcium pyrophosphate disease (CPPD). Many cases man (in his late twenties to early thirties). Morning stiffness
of pseudogout are idiopathic, but pseudogout has also lasts at least 1 h and improves with exercise (diagnosis
been associated with aging, trauma, previous joint disease clincher). Stiffness of the spine and kyphosis results in a
and many different metabolic abnormalities. Most stooped posture that is characteristic of ankylosing
common associations with pseudogout are hyperpara- spondylitis at advanced stages. On examination patient
thyroidism, hypophosphatasia, hypothyroidism, Wilson shows positive Schober test (measures spine flexion) and
disease, DM, hypomagnesemia, and hemochromatosis. sometimes obliteration of the lumbar lordosis. Spine
It may be clinically indistinguishable from gout but fractures are common with minor trauma.
here the most commonly affected joint is knee joint along Extraarticular manifestations are common in AS:
with others like shoulder, wrist, or ankle. Patient may Anterior uveitis, aortic insufficiency that may sometimes
present with recurrent inflammatory arthritis. lead to congestive heart failure, and third-degree heart
block.
Diagnosis
Joint fluid examination: It shows typical rectangular, Diagnosis
rhomboid, positive birefringent crystals on synovial Typical history and examination are very helpful.
fluid evaluation. X-rays: It is most helpful in diagnosis. The lesions on
X-rays: It may reveal linear radiodense deposits in joint X-ray progresses from blurring of the subchondral bone
menisci or articular cartilage (chondrocalcinosis).
plate to irregular erosions of the margins of the sacroiliac
joints (pseudowidening) to sclerosis, narrowing, and
Treatment
finally, fusion. Chronic spine inflammation will eventually
Same as gout. cause the bamboo spine and squaring of the vertebral
bodies.
SPONDYLOARTHROPATHIES (SPAS)
Treatment
They are a family of related disorders that includes
ankylosing spondylitis (AS), Reiter syndrome (RS), NSAIDs, physical therapy, and exercise are very helpful.
reactive arthritis (ReA), psoriatic arthritis (PsA), Sulfasalazine is often used in the treatment of ankylosing
spondyloarthropathy associated with inflammatory spondylitis, especially for peripheral joint involvement,
bowel disease (IBD), undifferentiated spondy- for which it has demonstrated efficacy. Treat extra-
loarthropathy (USpA), and, possibly, Whipple disease and articular manifestations as dictated by the clinical setting.
Behet disease. Ankylosing spondylitis is the prototypical
SpA. First step of diagnosis in all these diseases is X-ray of Reactive Arthritis
lumbosacral spine. The SpAs share certain common
features like: It is a chronic form of arthritis featuring inflamed joints,
Genetics ( HLA-B27) conjunctivitis, and inflammation of the genital, urinary,
Seronegativity or gastrointestinal systems. Its called reactive immune
Extraarticular manifestations system that is reacting to the presence of bacterial
Enthesitis (entheses-the location where a bone has an infections in the genital, urinary, or gastrointestinal
insertion to a tendon or a ligament). systems.
52 The Definitive Review of Medicine for USMLE
Cauda equina syndrome Saddle anesthesia, bowel and Immediate MRI. Surgical evacuation
bladder incontinence. Its a
medical emergency.
Spinal stenosis LBP typically worsens on Order lumbar X-ray to rule out Surgical evacuation
standing and walking but other pathologies.
improves on sitting or stooping
forward
(diagnosis clincher)
Neoplastic mass In elderly patients who present Lumbar X-ray Radiotherapy or surgery
(primary/metastatic) with weight loss or prior history of
cancer.
Ankylosing spondylitis In young patient. Typically worse Lumbar spine X-ray, AP pelvic X- NSAIDs and physiotherapy
in morning, reduced spinal ray
mobility. Extraarticular
manifestations as mentioned
earlier.
Osteomyelitis Presents along with history of Lumbar X-ray Specific antibiotic. Sometimes
fever, IV drug abuse, chills surgery may be required
Rheumatology 53
99er- Cervical stenosis- impinges on spinal cord and 99er-anti-Jo-1 autoantibodies are seen in patients with
presents with falls and spastic gait along with inflammatory myopathies.
hyperreflexia and upgoing toe.
99er-Knee painMost common cause of knee pain
Dermatomyositis is diagnosed when patients of
in < 45-year-old is patellafemoral syndrome, in which knee
polymyositis develop cutaneous manifestations like
heliotrope rash (violaceous periorbital rash) on face, pain is provoked by climbing stairs or prolonged sitting.
eyelids, and sun-exposed areas of the body and Gottrons Patient also shows retropatellar pain and crepitation on
papules (scaly lesions on knuckles of hand). vigorous patellar compression.
Polymyalgia rheumatic Pain and stiffness of shoulder and pelvic Anemia, highly elevated
girdles, fever, malaise, difficulty getting out ESR
of chair or lifting arm above head in absence
of any objective weakness (diagnosis
clincher)
Fibromyalgia Typically in women >50 years old. >10 out of 18 trigger point Low dose prednisone.
Weakness, fatigue, myalgias in absence of illicit pain (else its Stretching, heat application,
inflammatory. Associated with depression, myofascial pain stress reduction, psychotherapy,
anxiety, IBS. syndrome) electrical nerve stimulation
(TENS)
Polymyositis (striated muscle In older women. Symmetric, progressive, Elevated serum High dose corticosteroids.
inflammation) proximal muscle weakness and pain. Also creatinine, aldolase, CPK. Immunosuppressants if
has difficulty rising from chair. Eventually Fibrillations seen upon unresponsive to steroids.
difficulty breathing or swallowing. May EMG. Muscle biopsy is
develop myocarditis, conduction defect, or confirmatory.
malignancy.
99er-Plica syndromePresents as pain, snapping, popping, crepitus and effusion related to patellaofemoral joint
motion, overuse, or trauma. It mimics torn medial meniscus.
SMALL VESSEL Palpable purpura, arthritis, Direct immunofluorescence Often self-limited and
INVOLVEMENT glomerulonephritis, shows IgA on biopsy requires no treatment.
Henoch-Schnlein purpura intestinal ischemia sections, deposited in Steroid therapy for some
vessel walls of affected cases of gastrointestinal or
tissues. renal involvement.
SMALL AND MEDIUM Peripheral neuropathy, p-ANCA positive, other High-dose corticosteroids,
VESSEL INVOLVEMENT mononeuritis multiplex, nonspecific inflammatory often with cytotoxic agents
Polyarteritis nodosa intestinal ischemia, renal changes commonly like cyclophosphamide.
ischemia, testicular pain, observed.
livedo reticularis.
Contd...
54 The Definitive Review of Medicine for USMLE
Contd...
LARGE VESSEL Headache, polymyalgia ESR > 50 is diagnostic Immediate (to prevent
INVOLVEMENT rheumatica, jaw or tongue criteria. Temporal artery blindness) high-dose
Giant cell/temporal arteritis claudication, scalp biopsy is definitive test corticosteroids
(> 55 years of age) tenderness (on combing)
[diagnosis clincher], fever,
vision disturbances and
monocular blindness
Takayasus arteritis Extremity claudication, Lab tests are non-specific. High-dose corticosteroids
(Pulseless disease) athralgias, constitutional VCAM-1 is being proposed
symptoms, renal ischemia. as a marker for disease
No pulse in upper limb
positive drawer means injury to anterior talofibular bronchi and larynx. Severe cases may have floppy ears
ligament. and saddle nose due to destruction of cartilage. It is
99er-Behet syndrome- characteristically presents associated with RA, SLE and systemic vasculitis.
with painful oral and genital ulcer, ocular disease 99er-Gonococcal arthritis: It is characterized by initial
(relapsing iridocyclitis), skin lesions (papule, pustule,
presentation of acute onset of tenosynovitis.
folliculitis), migratory thrombophelibitis, and large joint
99er-Metatarsal stress fracture is a common sports
arthritis.
99er-Relapsing polychondritis is an autoimmune injury, involving 2nd, 3rd and 4th metatarsals. X-ray
disease characterized by bilateral swelling of ears doesnt show fracture until 2-3 weeks of injury. Patient
(diagnosis clincher), nasal involvement, symmetric arthritis may illicit tenderness at swollen site. No cast is usually
(costochondral joints) along with involvement of trachea, required and the fracture heals of its own in 3-10 weeks.
56 The Definitive Review of Medicine for USMLE
Chapter
4 Cardiovascular System
Dietary modifications include total fat, saturated fat, Lower extremity disease: Exercise should be done to
alcohol intake, etc. improve functional capacity.
99er- Hypertriglyceridemia in overweight patient- Medical management: Cilostazol has helped increase pain
weight reduction is primary mode of treatment. Restrict free walking distance by around 50% but it is relatively
dietary saturated fats and avoid alcohol and OCPs. If these contraindicated in patients with congestive heart failure.
steps dont help, try nicotinic acid or gemfibrozil. Pentoxifylline has also shown some benefit.
99er- Most important predictor of adverse outcome is Other modalities include angioplasty and surgical
DM, especially in women. revascularization.
Mesenteric disease/renal artery stenosis: Angioplasty
Peripheral Vascular Disorder or surgical revascularization.
It is atherosclerotic disease of vessels other than coronary
ISCHEMIC HEART DISEASE (IHD)
arteries. Risk factors are same as for CAD.
Coronary arterial narrowing due to atherosclerotic plaque
Clinical Features formation leads to insufficient blood supply to heart
leading to IHD. This stenosis of artery is aggravated by
Depending on organ effected:
formation of platelet microthrombi due to local damage or
Lower extremity: Diminished pulses, claudication,
loss of endothelium at site of atherosclerotic plaque.
skin atrophy, loss of hair, ulceration, bruit over effected
Risk Factors: As mentioned for CAD.
artery. Can be confused with spinal stenosis but
claudication improves with standing still whereas
Clinical Manifestation
spinal stenosis pain relived by sitting.
Mesenteric ischemia: Postprandial abdominal angina IHD presentation may range from being clinically silent to
and food avoidance which may cause the patient to angina pectoris to fatal myocardial infarction (MI)
become thin.
CNS: Stroke and TIA Angina Pectoris
Kidney: Bruit may be heard over renal artery. May Transient cardiac hypoxia leads to paroxysmal chest pain
present with difficult to control hypertension. called angina.
Diagnosis Types
Lower extremity disease: 1. Stable angina: Occurs during or just after exertion and
Ankle-Brachial Index (ABI): a comparison in lower and is relieved by rest. Its called stable because pain
upper extremity BP. It is a helpful bedside tool for always elicited by same amount of exertion.
evaluation of peripheral vascular disease. Leg ischemia 2. Unstable angina: It shows worsening pattern, i.e. pain
is characterized by a decrease in ABI of at least 20% occurs with more frequency/for more duration/more
with exercise. Most patients with peripheral vascular severe symptoms on even lesser exertion. Pain occurs
disease have an ABI < 0.9, and those with severe on rest.
disease (rest ischemia), an ABI of < 0.4. An ABI >1.3 3. Prinzmetal (Variant) angina: Also at rest like unstable
indicates vascular calcification. angina and difficult to differentiate from it just on basis
Doppler ultrasound of signs and symptoms especially when pattern of
Angiography or MRA: Usually not used for diagnosis angina is not known. ECG shows ST segment
but during preparation for revascularization. elevation (transmural ischemia) during ischemic
Mesenteric disease: Angiography will reveal the lesion but episode, which is its characteristic (diagnosis clincher),
it is chiefly a diagnosis of exclusion. as compared to depression in above two angina. It is
Renal artery stenosis: Duplex, angiography or MRA. most often seen in women < 50 years of age. Ergonovine
test, to be performed with care, triggers vasospasm
Treatment and hence angina pain. Angiography shows clear
Risk factor (especially smoking) control is very important artery as prinzmetal angina is caused by coronary
part of treatment. arterial spasm.
Cardiovascular System 59
4. Diagnosing angina: Clues to the diagnosis can be had MI evaluation and in those angina patients whose resting
from presentationPain may present with: ECG is normal. Stress echo is more sensitive than stress
Characteristicssqueezing, pressing, heavy, burning ECG. Patient on high risk have following finding on
discomfort. exercise testing:
Locationsubsternal, anterior chest, sometimes Failure to increase BP with exercise
epigastric. Inability to complete stage I of Bruce Protocol stress
Radiationarms (to left more than right), neck, jaw, test.
back, epigastrium. Horizontal/sloping down of ST segment on exercise
Duration > 15 secs < 15 mins.
Contraindications
Pain reliefResting (stable angina), nitroglycerine.
Associated symptomsnausea, breathlessness, fatigue, Acute coronary syndrome
diaphoresis, palpitation. Decompensated heart failure
Severe aortic stenosis.
Associated signstachycardia, S4 gallop.
It will be nondiagnostic in:
PrecipitatorsExertion, anxiety, large meals, exposure Patients on quinidine, digitalis and procainamide
to cold, emotional or mental stress. Patients who are not able to reach 85% of maximal HR
for age and sex
Diagnostic Tests Patients having left ventricular hypertrophy, WPW
ECG: This is always the initial test to be done in any patient syndrome, left bundle branch block, mitral valve
with chest pain, whatever diagnosis you have in mind for prolapse or nonspecific QT changes
the patient in question. Look out for ST segment Young women-up to 50% false positive.
depression. In these patients, treadmill testing with thallium is
99er-Important ECG changes: done.
In patients who cant exercise, testing is done after giv-
Peaked T waves: Seen in hyperkalemia, which may even
ing drugs that increase diameter of vessels like dipy-
lead to arrhythmia. This feature in ECG is a indication for
ridamole or adenosine or drugs that increase contractility
immediate treatment of hyperkalemia.
of heart like in Dobutamine echocardiography.
Prolonged QT interval: Seen in hypomagnesia, Exercise (pharmacologic) stress testing is the most
hypocalcemia. sensitive noninvasive method to establish the diagnosis
ST depression: In ischemic situation. If a ECG shows such of coronary artery disease.
a change, it should be compared with an old ECG and if
Cardiac catheterization: If above tests are positive, next
the change is found to be new, aspirin therapy should be
step is cardiac catheterization. This test helps to determine
started. It is also seen in hypothermia, hypokalemia,
the need for revascularization procedure, especially in
tachycardia, and digitalis.
patients who are poorly controlled with medical therapy.
T wave inversion: Also indication of ischemic event. After 99er-Directly go to this step in patients suffering with
comparison with old ECG, if the new one shows an upright ischemic diseases who are involved in public safety.
T wave, it denotes pseudonormalization which also
indicates ischemic event. It is also seen in chronic Differential Diagnosis
pericarditis, ventricular hypertrophy, and acute cerebral
injury. This is one of the most important topics, especially for CK.
You will find lots of questions mentioning chest pain with
U wave: Seen in hypokalemia. This feature also signals an
varied associated features and will ask you to diagnose
increased risk of arrhythmia and requires immediate
the condition. Using pretest probability by taking care of
correction of hypokalemia.
points like family history, immediate precipitating factors,
ST segment elevation: Infarction, variant angina, presence/ absence of risk factors you shall be able to reach
pericarditis, early repolarization. the diagnosis. Written below are the characteristic features
Stress testing: Next step after ECG is stress testing. that shall help you nail down these questions.
Exercise treadmill test/TMT: Used for confirming Gastrointestinal disorders: Most common cause of
diagnosis of angina and its severity. It is also used in post noncardiac chest pain.
60 The Definitive Review of Medicine for USMLE
GERD: Associated with regurgitation, pain made worse -blockers: They decrease mortality. Work by
after meals or by recumbent position and relieved by decreasing oxygen requirement.
antacids. Antiplatelet drugs: They also decrease mortality.
Pancreatitis: Pain radiates to back, abdomen tender Aspirin is the most commonly used drug. Clopidogrel
and elevated amylase. and Ticlodipine are alternatives to aspirin in those who
Esophageal spasm: Pain of spasm occurs after intake cant tolerate it. Choose clopidogrel if both options are
of cold fluid. Pain relieved by nitroglycerine, which given as ticlodipine can cause neutropenia.
makes it difficult to differentiate from angina. But Calcium channel blockers (CCBs): Have very limited
absence of associated cardiac symptoms will help use in angina patients. Used in long term treatment of
clinch the diagnosis. variant angina.
Peptic ulcer: Pain is epigastric and worsens few hours Revascularization: Useful in patients in whom medical
after meal. therapy fails or has severe side effects. In chronic
Gall bladder disease: Right upper quadrant pain and angina, coronary artery bypass graft surgery, a
tenderness. revascularization maodality is indicated for patients
Myocardial infarction: Severe pain that lasts more refractory to medical therapy; a large area of ischemic
than 20 minutes, patient is much more diaphoretic myocardium; high-risk coronary anatomy; and reduced
and anxious. Sometimes MI may be silent. left ventricular systolic function.
Aortic dissection: pain typically sharp and tearing, Coronary artery disease vasospasm is treated with
which radiates to back. Mediastinum widened on nitrates in the short-term and calcium channel blockers in
X-ray (both are diagnostic clincher) but the diagnosis the long-term.
should be confirmed on a CT/MRI . Look out for 99er- Highest perioperative risk is in patients of at
marfanoid features in the patient. rest angina and low critical AS.
Pulmonary embolism: Pain usually pleuritic with
prominent dyspnea, tachycardia and hypoxemia on UNSTABLE ANGINA/NON ST ELEVATION MI
lab values. Also look out for predisposing features. (ACUTE CORONARY SYNDROMES)
Pneumothorax: Pain is sudden in onset and pleuritic
Clinically presents as severe angina or MI. Absence of ST
in character. Dyspnea as major symptom and breath
segment elevation helps to distinguish it from MI. Pain of
sounds absent.
unstable angina is only partially relived by nitrates, which
Pleuritis: Sharp pain associated with inspiration
may also help to distinguish it from MI.
and friction rub on examination.
Pericarditis: Look for preceding viral illness in
Diagnosis
history. Pain is sharp, pleuritic and positional
which is typically relieved by leaning forward. On basis on presenting features and ECG findings.
Pericardial rub and diffuse ST segment elevation
on ECG. Treatment
Myocarditis: Pain is vague and mild. Preceding viral Apart from the treatment mentioned for angina, low
illness is seen here also. Cardiac enzymes often molecular weight heparin is mainstay of therapy.
elevated. Thrombolytics are not indicated here. Glycoprotein IIb/
Valvular disease: Look out for typical murmurs. IIIa inhibitors like abciximab are used if treatment
Muskuloskeletal disordrers: Chest wall typically mentioned above doesnt provide relief or the patient has
tender with absent ECG changes. It is seen in to undergo revascularization. Patient risk for acute
costochondritis (Tietze syndrome) or bruised and coronary syndrome can be determined from the TIMI risk
broken ribs. score. Patients at intermediate or high risk for acute
Treatment coronary syndrome should be considered for an early
invasive approach. If the patient dose not go for bypass
Nitrates: These are the first drugs given to patients surgery, clopidogrel should be given. Coronary
with angina to relieve pain. They do not decrease angiography is indicated in patients with a history of
mortality. Requires a drug free period of at least 8 hours unstable angina or non-ST-elevation myocardial
to show its effect. infarction.
Cardiovascular System 61
when thrombolytics are contraindicated or fail Life style modifications: Lipid management with statins
Patients develops CHF, hemodynamic instability, if LDL > 100.
ejection fraction < 40%. Stress testing: All post MI patients should undergo a
high risk ventricular arrhythmias submaximal (after 5-7 days) and maximal (after 2-3
new left bundle branch block weeks) stress testing. If it comes out to be positive, next
recurrent ischemic attacks step is to undergo angiography to determine the need
Glycoprotein IIb/IIIa inhibitors are used during this for angioplasty or bypass surgery.
procedure and aspirin along with clopidogrel is used after
the procedure. Complications of MI
In patients treated with coronary artery stenting for
coronary artery disease, statin therapy is recommended Suspect complications like papillary muscle rupture,
even in the absence of elevated total cholesterol. ventricular wall rupture or cardiac tamponade if patient
99er-Peripheral ischemia after an arterial catheteri- suddenly develops shortness of breath. Various
zation suggests cholesterol embolism syndrome. The complications seen are:
incidence of cholesterol embolism syndrome after coronary Electrical disturbance: Dysarrythmias like bradycar-
artery catheterization is increased in patients with dias, tachyarrhythmias and conduction abnormalities
atherosclerotic disease, hypertension, a history of smoking, like AV nodal block and intraventricular block.
and baseline elevation of C-reactive protein. Failure of pumping action: This may be because of
99er-Inferior wall MI shows sinus bradycardia which electromechanical dissociation, ventricular failure due
requires treatment if patient is hemodynamically unstable. to infarct expansion or ventricular aneurysm
First step in management of symptomatic bradycardia is development or mechanical disruption which requires
IV atropine. Next step is revascularization or thrombolytics corrective surgery.
use and last resort is transvenous pacing. Papillary muscle dysfunction or rupture: Peak incidence
99er- Cocaine MI- Its treatment involves nitrates or 3-5 days after infarct and more frequent in
CCB plus aspirin (to counteract its platelet aggregating inferoposterior infarct. It is suspected in patients with
effect) along with benzodiazepine. If there is no MI when clinical signs of acute mitral regurgitation
improvement, next step is angioplasty. Cocaine can also appear after MI episode. An echocardiogram should
cause stroke, myocarditis and arrhythmias. be performed if papillary muscle dysfunction is
99er-Drugs used in treatment of CAD that lower suspected. Mitral regurgitation due to papillary muscle
mortality- aspirin, -blockers, statins, ACE inhibitors. dysfunction gives usually loud and holosystolic
99er- Sex can be resumed 6 weeks after MI. murmur which often improves following coronary
99er- CCB are to be used in treatment of MI only when revascularization.
-blockers are contraindicated. Otherwise stop them even Ventricular septal rupture: Its peak incidence is also
if previously being used. 3-5 days after infarction but is more commonly seen
with anterior infarct. It gives a loud and holosystolic
Post MI Management murmur that radiates in a widespread area. On
pulmonary artery catheterization it shows a
Medical Therapy
characteristic step up in oxygen saturation of 10% in
Within 1st day start ACE inhibitors (if BP tolerates alive it) right ventricle and pulmonary artery as compared to
- it patients with: right atria.
ejection fraction < 40% Post infarction ischemia: If it leads to angina attack,
left ventricular dysfunction angioplasty or bypass surgery is indiacted.
They are recommended for at least first 6 weeks, as Sudden cardiac death: This is most often due to
they decrease mortality by preventing infarct remodeling. arrhythmias and that too ventricular fibrillation.
Aspirin Sometime arrhythmias may develop in patient without
Switch to oral -blockers: They also decrease the actual MI, just by episodes of ischemia
incidence of non fatal reinfarction and recurrent Thromboembolic events: Due to development of mural
ischemic effect. They are known to decrease both thrombus or deep vein thrombosis out of long term
mortality and infarct size. immobilization post MI.
64 The Definitive Review of Medicine for USMLE
Inotropic agents: add if above drugs dont work. They *99er- Corrigan Pulse: Rapid rise and fall in peripheral
do not decrease mortality. They include digoxin, pulses, seen in AR and also in hyperthyroidism, large AV
phosphodiaesterase inhibitor like amrinone, milrinone fistula, beriberi, patent ductus arteriosus.
or intermittent dobutamine. Duroziez sign: Systolic or/and diastolic thrill or
Digoxin doesnt lower overall mortality. murmur heard over femoral artery.
Spironolactone: can be given along with ACE-I, 99er- Mill wheel murmur: A loud cheerning,
blockers, diuretics and digoxin. It is known to decrease machinery like murmur characteristic of air embolism.
mortality.
An ACE inhibitor and a -blocker are indicated in all Other Valvular Disorders
patients with systolic heart failure, including
asymptomatic patients. Pulmonary Regurgitation
The addition of hydralazine and nitrates to standard Early diastolic murmur, decrescendo, high pitched,
heart failure therapy in blacks with severe heart failure blowing, best heard around the left sternal border and
improves mortality. usually develops secondary to pulmonary hypertension.
In patient with advanced CHF, water restriction is It becomes more prominent with inspiration.
mainstay of therapy. Hypertonic saline is used in rare case
when water retention leads to symptomatic hyponatremia. Pulmonary Valve Stenosis
Morphine given to patients of CHF has two beneficial
On physical examination patient shows persistently wide
effects; it helps reduce anxiety and also dilates venous bed
split S2. A right ventricular heave may also be felt. Noonan
to decrease preload.
syndrome should always be considered in a patient with
pulmonary valve stenosis, which is characterized by short
Nonpharmacological Treatment
stature, intellectual impairment, unique facial features,
It involves reduction of salt intake along with reduction of neck webbing, and congenital heart defects.
physical, mental and emotional stress. 99er- Persistently wide split S2: Seen in patient with
Perform surgical correction for valvular disease. Also pulmonary stenosis, right bundle branch block,
consider heart transplant if patient develops end stage pulmonary embolus and ectopic or pacemaker beats
cardiac failure. originating in ventricle. It can also be seen in patients
Diastolic dysfunction: The primary treatment goals in suffering with Chagas disease, a disease endemic in central
diastolic heart failure are to treat the underlying etiology if and South America, which may also cause heart block
possible, to manage any potentially exacerbating factors, along with other rhythm disturbance, cardiomyopathy
and to optimize diastolic filling. Use diuretics if evidence and thromboembolism.
of volume overload is present. blockers and CCBs are
also effective. But avoid diuretics and digoxin as first line Tricuspid Regurgitation
treatment. A pansystolic murmur at the left sternal border.
Cor Pulmonale: Right ventricular failure, or enlargement
and failure due to primary lung disease. The most common Tricuspid Stenosis
cause is chronic obstructive pulmonary disease (COPD) it A mid diastolic rumble, best heard along the left lower
may even be caused by chronic sleep apnea. Clinical sternal border.
features, in addition to pulmonary disease, include
tachypnea, clubbing, cyanosis, parasternal heave, loud Prosthetic Valves
P2 and right sided S4.
Any patient with a prosthetic valve and an
VALVULAR HEART DISEASE unexplained fever should be suspected to have
infection.
Physical examination is helpful in identifying the presence The clinical evaluation for prosthetic valve
but not the severity of valve disease. Echocardiography is endocarditis must include a transesophageal
indicated if physical examination shows a systolic murmur echocardiogram as transthoracic imaging alone cannot
(> grade 3/6 in intensity), continuous murmur or any fully assess the valve for valvular dehiscence,
diastolic murmur is of first choice. dysfunction or paravalvular abscess.
66 The Definitive Review of Medicine for USMLE
Table 4.3
Lesion Sign Symptom Misc. fact Treatment
Mitral Blowing systolic Heart failure Chronic MR dilates Acute cases usually
regurgitation (MR) murmur radiating symptoms if severe, else atria and may requires surgery
to axilla. Soft S1 asymptomatic. predispose to Asymptomatic chronic
with widely split Pulmonary atrial fibrillation. MR requires repair or
S2. Distended neck hypertension may Echo is the replacement of valve
veins. Large v wave develop as a late technique of choice to only if symptomatic or
on catheterization. finding. evaluate mitral valve if ejection fraction drops
abnormalities. below 60% or the left
Doppler ultrasound ventricular systolic
can be used after echo dimension > 45 mm or
to evaluate trans end diastolic > 60 mm.
valvular gradients. Nifedipine may delay
the timing of surgical
intervention in these
patients.
Mitral valve Midsystolic click Asymptomatic usually. Associated with Prophylaxis against
prolapsed (MVP) (characteristic), late Most symptoms if increased incidence of endocarditis in cases
systolic murmur present are due to sudden death, infective who have MR, murmur
(at apex) if MR present. arrhythmias. endocarditis, embolism, heard on auscultation,
arrhythmias, palpitation or if the patient has
and panic attacks high-risk
echocardiographic
features. Also give
blockers.
Mitral stenosis (MS) Diastolic rumbling Hemoptysis, Rheumatic fever is most Valve replacement,
murmur (at apex) with Hoarseness (due to common etiological balloon valvuloplasty.
opening snap. AF, impingement of factor. Two third Diuretics and salt
decreased pulse enlarged left atrium on patients are female. restriction. Drugs to
pressure, sternal lift, recurrent laryngeal Previously control HR
loud S1. nerve) and HF symptoms undiagnosed mitral
stenosis often first
becomes symptomatic
during pregnancy.
Aortic stenosis (AS) Harsh systolic, The classic triad of The most sensitive sign Surgery for all
crescendo-decrescendo symptoms is syncope, on physical examination symptomatic (SAD-
murmur radiating to angina, and dyspnea on to exclude the diagnosis Syncope, angina,
carotids. Severe stenosis exertion. At symptom of severe aortic stenosis dyspnea) patients or
shows small and slow onset, patients with is a physiologically when valve area
carotid upstroke and severe aortic stenosis split S2. Survival in < 0.8 cm2.
pulse is known as may have only subtle patients with severe Use balloon
parvus et tardus. S4 symptoms such as asymptomatic aortic valvuloplasty for
gallop. S2 single or dyspnea on exertion or stenosis is similar to that patients who are too
paradoxically split. a decrease in exercise of age-matched normal ill to tolerate surgery.
Point of maximum tolerance. adults. Avoid vasodialators
impulse shifted down and overdiuresis.
and out. Patient should receive
endocarditis
prophylaxis.
Aortic Chronic AR shows wide Advanced cases show Associated with Valve replacement if
regurgitation (AR) pulse pressure symptoms of heart ankolysing spondylitis, symptomatic or
(characteristic). failure. Otherwise marfans syndrome, decreased ejection
Soft high pitched asymptomatic. syphilis and aortic root fraction. Afterload
decrescendo diastolic dissection. Rheumatic reduction with
murmur (apex). Austin- fever is the most ACEIs or hydralazine.
Flint murmur. common cause. Endocarditis
prophylaxis also
required.
Prosthetic valve dehiscence or dysfunction should be CXR: cardiomegaly and pulmonary congestion
suspected in patients that develop symptoms of ECG: arrhythmias and conduction abnormalities
congestive heart failure, particularly if these symptoms Echo: this is most important investigation which shows
occur in the first 6 months following surgery. dilated ventricles, decreased wall motion and mitral valve
Mechanical valve thrombosis may present with valve regurgitation may also be present.
dysfunction rather than embolic events and
intravenous heparin should be started immediately Treatment
while diagnostic evaluation is going on.
Similar to CHF. There is high risk of embolization due to
99er-Age dependant idiopathic sclero-calcific
sluggish blood flow in dilated ventricles. Therefore
changes are the most common cause of isolated AS in
anticoagulation with warfarin should be maintained.
elderly.
99er-Bacterial endocarditis may lead to aortic Associated arrhythmias can be prevented by
insufficiency but not aortic stenosis. antiarrhythmic like procainamide or quinidine.
A disease involving heart muscles is called There is marked hypertrophy of ventricles, usually left side,
cardiomyopathy. They are classified according to along with disproportionate hypertrophy (asymmetric
pathological and hemodynamic characteristics into hypertrophy) of ventricular septum in majority of cases. It
following types: is usually herediatary and shows autosomal dominant
transmission.
Dilated Cardiomyopathy Hypertrophy leads to decrease in compliance and
hence diastolic dysfunction. The heart becomes hyper
As the name suggests, it usually involves biventricular
contractile and ejection fraction may be markedly
dilation leading to decreased heart contractility.
increased. Left ventricle may almost be obliterated during
Etiology systole by coming together of septum and septal leaflet of
mitral valve. This obliteration or obstruction to outflow is
Idiopathic increased by factors that increase contractility or reduce
Alcoholic* preload and afterload and vice-versa.
Postmyocarditis
Peripartum Preload Decrease Valsalva maneuver, standing,
Gycogen storage disease, fabry disease, gaucher disease nitroglycerine, tachycardia.
Metabolic disorder like hypokalemia, hypocalcemia,
Increase Squatting, bradycardia,
uremia
blockade, intravascular volume
Beriberi expansion
Toxins like lead, arsenic and drugs like doxorubicin,
vincristine. Afterload Decrease Hypovolemia, nitroglycerine,
vasodilator drugs
Increase Squatting, hand grip exercise,
Clinical Features adrenergic stimulation,
Similar to CHF. Therefore it is also known as congestive intravascular stimulation.
cardiomyopathy. It may be associated with functional
mitral or tricuspid regurgitation.
Clinical Features
Diagnosis In exam the first manifestation in most questions on this
Presence of typical etiological factors along with clinical topic is sudden death or syncope in an athlete. Clinical
presentation should help you reach diagnosis. To confirm: features that predict high risk for sudden cardiac death
* Alcoholic cardiomyopathy is a dilated cardiomyopathy and its management must include total abstinence from alcohol.
68 The Definitive Review of Medicine for USMLE
* Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
Cardiovascular System 69
Diagnosis
ECG shows pulsus alternansamplitude of QRS complex
changes from beat to beat. Echo is very effective in First Degree AV Block
diagnosis. Cardiac catheterization shows equalization of
pressure in both atrias. First Degree Block
PR interval on ECG > 0.20 sec at a HR of 70/min. Avoid -
Treatment
blocker and CCBs.
Pericardiocentesis if symptomatic.
99er- An uncomplicated pericardial effusion due to Second Degree Block
hypothyroidism requires nonspecific therapy other than
It is of two types:
thyroid replacement. Persistence of a pericardial effusion
in excess of 3 months warrants pericardiocentesis.
Type I Block
Pericardial effusion is not pathognomonic of pericarditis.
Type I/Mobitz type I/Wenckebach: Associated with
RATE AND RHYTHM DISTURBANCES digitalis toxicity, increased vagal tone and inferior
wall MI. ECG features:
SA Node Dysfunction PR interval increases until a P wave is completely
blocked and a ventricular beat dropped.
Next PR interval is shorter than the preceding one.
RR interval goes on decreasing till the beat gets
dropped.
QRS complex is normal in width.
If it progresses to complete block, HR remains >
45/min with narrow QRS complex and Adams-Stoke*
attacks are uncommon.
Sinus Bradycardia
Sinus Bradycardia
HR < 60/min with evenly spaced and normal width
complexes.
Type II Block
Etiology
Type II/Mobitz II: Associated with anterior wall MI
Excessive vagal tone and also cases involving calcification of mitral or aortic
Hypothermia valve annulus. There is no effect of carotid sinus
Hypothyroidism pressure. ECG features:
Depression of SA Suddenly a beat is dropped without any change in
preceding PR interval, which remains normal in
Treatment duration. If it is prolonged, the duration of
Only when symptomatic or according to some also when prolongation remains fixed.
HR < 40/minute. Atropine is first line of drug. Intravenous RR interval of conducted beats usually remains
pacemaker is used if atropine fails to work. constant.
Cardiovascular System 71
Etiology
Inferior or posterior wall MI.
Ankolysing spondylitis with evidence of association PR interval and shape of P wave differs from wave to wave.
with HLA-B27. The rhythm is irregular with rates of 100-200 beats/min
Lenegre diseaseIt is fibrotic degenerative change in and there should be at least 3 different shapes of P waves
conduction system due to aging. It is commonest cause for it to be diagnosed. It is seen in chronic pulmonary
for complete block in adults. disease patients, old age people, hypokalemia, hypomagne-
Inflammatory processes involving myocardium. semia, valvular disease, aminophyllin.
Treatment: Therapy for multifocal atrial tachycardia is
Clinical Manifestation directed at treating underlying pulmonary disease and
Adams-Stoke attacks-Circulatory arrest due to sudden correcting electrolyte imbalances.
asystole or ventricular tachyarrhythmias. Symptoms are
assocoiated with these attacks or congestive failure occurs
in patients with pre existing myocardial disease.
Treatment
First degree and type I second degree block may respond
to IV atropine, which is normally used for reversing
excessive vagal tones in emergency like acute MI. Complete Paroxysmal Supraventricular Tachycardia
heart block with slow ventricular rate can be given
epinephrine or isoproterenol before setting up permanent It (includes paroxysmal atrial tachycardia): Initiated by
pacing. Pacing is required in all symptomatic heart blocks. supraventricular premature beats, they are caused mostly
99er- Induction of mild hypothermia has been shown due to re-entry through AV node. Often associated with
to improve outcome in comatose survivors of out-of- perfectly normal heart. They are characterized by sudden
hospital cardiac arrest. onset and abrupt termination of tachyarrhythmias of
regular rhythm with typically 160-220 beats/min which
Supraventricular Arrhythmias arise from ectopic sites.
Treatment: If carotid sinus massage done on only one side
for 10-20 seconds in semi recumbent position fails, IV
verapamil and adenosine are the drug of choice. Presence
of carotid bruit is absolute contraindication for carotid
massage. Other drug options are propranolol or IV
digitalization. Radiofrequency catheter ablation is also a
72 The Definitive Review of Medicine for USMLE
very effective treatment option. Last resort is synchronized Atrial fibrillation is notorious for systemic
external cardioversion. embolization, which is very important entity to be taken
care of during management of AF. Lone AF is one where
no reason is found for it. In this case aspirin is enough to
prevent stroke.
Treatment
Initial modality of choice is cardioversion.
Pharmacological treatment includes IV digitalis,
propranolol, IV verapamil. If still persists, quinidine and
procainamide may be used. Procainamide and ibutilide
are the drugs of choice in the treatment of preexcited atrial
fibrillation. Ask the patient to stop alcohol.
To prevent embolism, warfarin therapy should be
Atrial Flutter
started 3 weeks before cardioversion and should be
Regular rhythm with a 2:1 block at AV nodal level leading continued for atleast 4 weeks after normal rhythm is
to an atrial rate of 250-300 beats/min and a ventricular achieved. But in low-risk patients with lone atrial
rate of 125-150 beats/min. fibrillation, warfarin anticoagulation is not required.
Aspirin or no therapy is recommended in these patients.
ECG: Saw-tooth pattern flutter waves most noticeable in
Sometimes, a heparin therapy bridge is required after
the inferior leads.
stoppage of warfarin therapy and before a major surgery.
Seen in alcoholics, thyrotoxicosis, mitral valve disease
High risk patients that require a heparin anticoagulation
patients, COPD and pulmonary embolism patients.
bridge include those with a mitral mechanical valve, atrial
fibrillation, or previous embolism.
Treatment
99er- In patients on warfarin who develop a
Digitalis or verapamil are the drugs used. In microcytic anemia, a gastrointestinal lesion should be
hemodynamically unstable patients synchronized suspected.
cardioversion is used. The preferred treatment for recurrent 99er- Atrial arrhythmias are a common indication of
atrial flutter is radiofrequency catheter ablation. repaired tetralogy of Fallot residua. Long-term regular
99er- Synchronized cardioversion is done in atrial follow-up is required in all patients with repair of complex
fibrillation, Supraventricular tachycardia and stable congenital heart disease.Pulmonary valve regurgitation
ventricular tachycardia. is the most common long-term complication following
Desynchronized cardioversion/defibrillation done in surgical treatment for tetralogy of Fallot
unstable/pulseless ventricular tachycardia and
ventricular fibrillation. Ventricular Arrhythmias
Premature ventricular contractions: Common in healthy
adults and is not a cause for concern. Their suppression is
indicated only in patients with severe and disabling
symptoms.
are mostly of re-entrant type. VT is common in CAD, Drugs that prolong ventricular repolarization like
cardiomyopathies, MVP, metabolic derangements, digitalis disopyramide, procainamide, quinidine, pheno-
toxicity, hypothermia. Long QT syndrome may also cause thiazines, TCA, lithium, thioridazine.
VT. It is commonly seen after acute MI. VT that persists for
more than 30 seconds is called sustained VT. Clinical Features
Patients are prone to dizziness and syncope. Sudden
Clinical Features
auditory stimulation like even phone ring at night may
AV dissociation leads to: precipitate torsades in vulnerable patients with long QT
Canon waves-intermittent peaks in jugular venous interval syndrome.
pressure when atria and ventricle beat together.
Variation in intensity of heart sound, along with some Treatment
extra heart sounds.
Cardiac pacing or IV isoproterenol is used for emergency
Variations in systolic BP. treatment. Do cardioversion in hemodynamically unstable
Other associated features are that of CHF, light
patients. In stable non emergent cases correct the
headedness, hypotension, syncope. Widely split S1 S2 is
underlying disorder or use antiarrythmic drugs that do
heard because of asynchronous excitation of two not affect or prolong ventricular repolarization like
ventricles.
lidocaine or phenytoin.
99er- TCA- inhibits fast Na+ channels and prolongs
ECG Features
QRS and re-entrant arrhythmia. Most effective treatment
No P waves are visible. QRS complexes are bizarre in shape is sodium bicarbonate. Lidocaine is drug of choice in TCA
and wide. induced ventricular dysarythmia.
Treatment
VT patient with no pulse is treated on lines of ventricular
fibrillation.
Stable VTAmiodarone or lidocaine are the first drug
of choice for rate control. Procainamide can be given if
they fail. Use cardioversion if patient becomes unstable Ventricular Fibrillation (VF)
anytime.
Unstable VT: Cardioversion is done. Start with 100 J Electrical activity on ECG but no organized pattern.
and subsequently use 200 J, 300 J and 360 J. Etiology is almost same as VT.
For idiopathic ventricular tachycardia with refractory
Clinical Features
symptoms, radiofrequency catheter ablation has an
excellent cure rate. An unresponsive patient with VF on ECG.
99er- Atrial tachycardia with variable block is a 99er- Amiadarones most feared and life threatening
classic electrocardiographic finding in digitalis toxicity. side effect is pulmonary fibrosis. Other side effects are skin
The first-line treatment for life-threatening digitalis toxicity discoloration and hypotension (with IV formulation). It
is administration of digoxin-specific antibody fragments. also increases warfarin life and warfarin dose needs to be
decreased.
Nicotinic acid (niacin) LDL, HDL Flushing, hepatits Aspirin before dose
flushing
Bile acid binding resin- LDL Cramping and bloating Most patient are not
cholestyramine able to tolerate GI
effects
Calcium channel Angina, long-term Hypotension. In patients who had a May be harmful to post
blockers (CCBs) variant angina therapy Lightheadedness, CHF, cardiac index below MI patients if patient
headache, flushing, 2.0 L/minute/m2 already has LV failure.
weakness,
constipation, peripheral
edema, nausea,
wheezing
Anticoagulants Acute coronary Active bleeding, Heparin induced
(heparin) syndromes, MI and hemorrhagic diathesis, thrombocytopenia
follow up therapy to tPA recent major surgery (check out hematology
chapter)
Contd...
76 The Definitive Review of Medicine for USMLE
Contd...
ACE inhibitors Post MI patients, CHF Cough, angioedema, Pregnancy, bilateral First line drug in CHF.
taste change, rash, renal artery stenosis Decrease mortality.
hypotension,
hyperkalemia
5 Nephrology
FLUID AND ELECTROLYTE DISORDERS duction. The ECF is increased markedly, with the
presence of edema. It is commonly seen in:
Hyponatremia - Congestive heart failure
Sodium is the dominant extracellular cation. The normal - Renal insufficiency
serum sodium level is 135-145 mEq/L. Hyponatremia is - Nephrotic syndrome
defined as a serum level of < 135 mEq/L. Various type of - Cirrhosis
Hyponatremia and their etiologies are: Redistributive hyponatremia: Water shifts from the
Hypertonic (Posm > 295 mOsm/kg): Hyperglycemia, intracellular to the extracellular compartment, with a
hypertonic infusion like radiocontrast, or mannitol. resultant dilution of sodium. The TBW and total body
Isotonic (P osm = 280-295 mOsm/kg): Hyperpro- sodium are unchanged. This condition occurs with
teinemia, hyperlipidemia. hyperglycemia.
Hypotonic (Posm < 280 mOsm/kg): Further classified Pseudohyponatremia: The aqueous phase is diluted
by volume status: by excessive proteins or lipids. The TBW and total
Hypovolemic hyponatremia: Total body water (TBW) body sodium are unchanged. This condition is seen
decreases; total body sodium (Na+) decreases to a with:
greater extent. The extracellular fluid (ECF) volume - Hypertriglyceridemia
is decreased. Seen after GI losses, diuretics, and - Multiple myeloma
skin losses (Burns, cystic fibrosis, sweating, etc); it - Hyperglycemia (Na+ decreases by 1.6 mEq/L for
is the replacement with hypotonic fluid that gives every 100 mEq/L increase in glucose above
this hyponatremia. Its seen in: normal)
- Any GI loss 99er- Beer potomania- Patient who consume large
- Skin losses amount of beer, with poor dietary intake may develop
- Diuretics hyponatremia.
- Salt-losing nephropathies (interstitial renal 99er- MDMA/ecstasy-induced Hyponatremia-
disease) occurs via multiple mechanisms including the:
- Addison disease induction of SIADH
Euvolemic hyponatremia: TBW increases while total the encouragement to drink large amounts of water to
sodium remains normal. The ECF volume is prevent unpleasant side-effects of the drug
increased minimally to moderately but without the the tendency among those intoxicated to be involved
presence of edema. Its seen in: in vigorous physical activity that results in heavy
- Psychogenic polydipsia (at least >10-15 l/d sweating
intake is needed).
- Hypothyroidism Clinical Features
- Syndrome of inappropriate secretion of ADH The number and severity of symptoms increase with the
(SlADH) degree of hyponatremia and the rapidity with which it
Hypervolemic hyponatremia: Total body sodium develops. The symptoms of any cause of hyponatremia
increases, and TBW increases to a greater extent generally begin below a value of 120 mEq/L and are almost
secondary to decreased intravascular volume entirely neurologic in nature. Headache, lethargy,
which has increased baroreceptor stimulation and obtundation, and eventually seizures and coma are most
increased ADH (antidiuretic hormone) pro- common.
78 The Definitive Review of Medicine for USMLE
99er- In malnourished and dehydrated patients with Intravenous potassium is less well-tolerated and is given
hypernatremia who are no longer able to express thirst or in small doses of generally 10 mEq/L. Potential
hunger should be immediately put 5% dextrose with water, complication of too rapid repletion is fatal arrhythmia.
to be given relatively slowly, followed by normal saline. Magnesium should also be replaced, as its deficiency
makes K+ replenishment very difficult.
Hypokalemia 99erKetoacidosis- Apart from DM, other very
common causes of ketoacidosis are starvation and chronic
Serum potassium < 3.5 mEq/L. Nearly 98% of the bodys alcoholism. Alcoholics typically develop it after an
potassium is intracellular. Therefore, serum potassium alcoholic binge and vomiting followed by no food
levels can be a very poor indicator of total body stores. It consumption. They also have abdominal pain as a
can be caused by: prominent symptom. The mainstay of treatment is
GI losses-Vomiting, diarrhea, tube drainage hydration with 5% dextrose in normal saline.
Increased urinary loss (Conns syndrome, DKA,
diuresis, RTA) Hyperkalemia
Increased entry into cells (transcellular shift as in
Hyperkalemia is a potentially life-threatening illness as it
alkalosis, increased insulin, adrenergic activity)
can lead to sudden death from cardiac arrhythmias.
Bartter syndrome- is characterized by hypokalemia,
Therefore any suggestion of hyperkalemia requires an
hypochloremia, metabolic alkalosis, and hyperreni-
immediate ECG. It can be caused by:
nemia with normal BP. The underlying renal
Movement from cells to ECF
abnormality of juxtaglomerular hyperplasia results in
Tissue breakdown: Rhabdomyolysis, tumor lysis,
excessive urinary losses of sodium, chloride, and
after seizures or severe exercise.
potassium, resulting in increased renin, increased Acidosis-Secondary cellular buffering (H+ moves
aldosterone but normal BP. into cells, K+ out)
Insulin deficiency
Clinical Features Pseudohyperkalemia: Hemolysis (in laboratory tube)
Symptoms usually start when potassium falls to < 2.5 to most common, thrombocytosis, venipuncture
3.0 mEq/l. It usually presents with muscle weakness, technique (ischemic blood draw from prolonged
cramping, paralysis, cardiac arrhythmias, U-wave on tourniquet application), high platelet count
EKG, T-wave flattening, rhabdomyolysis, nephrogenic DI, (> 1,000,000), and WBC count > 100,000.
constipation, ileus, lethargy, decreased tendon reflex, etc. Decreased urinary excretion
Renal failure
Diagnosis Hypoaldosteronism: ACE inhibitors, Type IV RTA,
adrenal enzyme deficiency; heparin inhibits
ECG shows T wave flattening, U waves, and ST segment production of aldosterone
depression. Urine K+ should also be done: Potassium-sparing diureticstriamterene,
Urine K+ > 20 mEq/L: Indicates renal wasting of K+. amiloride, spironolactone
Further examine blood pH. NSAIDs
Metabolic alkalosis: Cushings syndrome, primary Increased intake
or secondary hyperaldosteronism, hypomag-
nesemia, diuretics. Clinical Features
Metabolic acidosis: lactic or ketoacidosis, type I RTA. It presents initially with muscular weakness (K+ levels
Urine K+< 20 mEq/L: Indicates nonrenal source, > 6.5), nausea, vomiting, intestinal colic, areflexia,
including GI losses, or transcellular shifts. muscular weakness (K+ > 6.5mEq/L) (last 3 diagnosis
clincher). Other findings may be generalized fatigue,
Treatment paresthesias, paralysis, and palpitations. Abnormal
First step should be preventing ongoing losses and cardiac conduction is the most common cause of death
correcting underlying cause. Then efforts should be made due to various arrhythmias. Hyperkalemia is medical
to replenish potassium losses. Oral potassium is absorbed emergency when there is an acute increase in serum K+
readily. Relatively large doses can be given safely. level > 7 or there is simultaneous metabolic acidosis.
80 The Definitive Review of Medicine for USMLE
Table 5.1
Disorder pH H+ Primary mechanism Compensatry mechanism
anion gap is frequently elevated to a modest degree in ACUTE RENAL FAILURE (ARF)/ACUTE
metabolic alkalosis because of the increase in the KIDNEY INJURY (AKI)
negative charge of albumin and the enhanced
production of lactate. However, the only definitive way It is defined as an abrupt or rapid decline in renal filtration
to diagnose metabolic alkalosis is by performing a function and is usually marked by a rise in serum
simultaneous blood gases analysis, which reveals creatinine concentration or azotemia (a rise in blood urea
elevation of both pH and PaCO2. nitrogen [BUN] concentration) or just decreased urine
production. It can be:
Pre-renal: Conditions with normal tubular and
RENAL TUBULAR ACIDOSIS glomerular function; GFR is depressed by compro-
mised renal perfusion
Renal tubular acidosis (RTA) refers to those conditions in Renal: Diseases of the glomerulus or tubule.
which metabolic acidosis results from diminished net Post-renal: Caused due to an obstruction to urinary
tubular H+ secretion or HCO3 reabsorption. Three major flow out of kidney that increases the tubular pressure
types of RTA exist: and decreases the filtration driving force.
Table 5.2
Primary defect decrease in net H+ excretion in proximal HCO3 reabsorption is Results from aldosterone
the collecting tubules reduced (usually self limiting) deficiency or resistance
Diagnosis Continued H+ retention, plasma plasma HCO 3 concentration Hyperkalemia with a concomitant
HCO 3 concentration reduced usually is 14-20 mEq/L Hyperchloremic metabolic aci-
(10), low blood-potassium. Acid dosis (non-anion gap);
load test-give ammonium chlo-
ride, which should lower urine pH
secondary to increased
H+ formation.
Urinary pH > 5.5 > 5.5 initially; < 5.5 once serum is < 5.5
acidic
Treatment Oral bicarbonate because Mild volume depletion (enhances Fludrocortisone, furosemide,
bicarbonate reabsorption in the proximal bicarbonate reabsorp- kayexalate
proximal tubule still works; tion-contraction alkalosis).
potassium replacement. Thiazide diuretics, very large
amounts of bicarbonates;
replenish potassium
82 The Definitive Review of Medicine for USMLE
pH Failure to acidify urine pH < 5.5 in metabolic acidosis settings suggests distal renal tubular
acidosis.
Alkalosis: Proteus in UTI or some strains of Klebsiella Pseudomonas
acidosis (with renal stone): Either cystine or uric acid stone
Specific gravity Gives rough estimation of osmolarity of urine
Nitrite May be +ve in G-ve bacteria in urine
Leukocyte esterase Suggestive of UTI since it is produced by WBCs.
Proteinuria Urine dip test: doesnt detect non-albumin proteins (globulin, Bence jones proteins)
Glucosuria In hyperglycemia
Ketonuria In starvation, alcohol intoxication, uncontrolled diabetes, pregnancy, post exercise
Hematuria +ve when myoglobin, hemoglobin, RBCs present in urine.
Bilirubin In conjugated hyperbilirubinemia
Urobilinogen urobilinogen: in biliary obstruction
urobilinogen: in hemolysis, hepatocellular disease
Epithelial cells Excessive number of epithelial cells suggest a contaminated urine sample
NSAIDs affect kidneys adversely at different levels: There is a latent period after the infection; typically
Hemodynamic deterioration: Prostaglandin inhibition 1-2 weeks for postpharyngitis cases and 2-4 weeks for
by NSAIDs leads to renal vasoconstriction. cases of postdermal infection. The course of disease is
Interstitial nephritis: By direct toxin effect and papil- typically self limited and presents with 'smoky' urine due
lary necrosis. to hematuria, oliguria, edema particularly of periorbital
Papillary damage with calcification that leads to area, proteinuria and hypertension.
papillary necrosis and acute colic pain.
NSAIDs associated hypertension- an average increase Diagnosis
of 8-10 mm of Hg of mean arterial pressure of patient Biopsy is rarely needed. Tests that are most helpful to reach
on NSAIDs. diagnosis are the serological tests including ASO and
Patient typically presents with long history of high AHT (antihyaluronidase) and C3, CH50 and normal C4
dose (around 1 g/day) NSAIDs along with flank pain levels. Immunofluorescence shows lumpy-bumpy pattern.
(diagnosis clincher) and hematuria, pyuria, and
proteinuria of nephrotic range due to papillary necrosis. Treatment
deposition and lipid laden renal cortices. Patients have a END STAGE RENAL DISEASE (ESRD)
tendency towards infection and thrombotic events.
Chronic renal failure (CRF) requiring dialysis or
Membranoproliferative Glomerulonephritis transplantation is known as end-stage renal disease. In
(MPGN) the United States, major causes that lead to approximately
75% of all adult cases are:
Refers to a pattern of glomerular injury based on diabetic nephropathy
characteristic histopathologic findings of mesangial
hypertension
expansion, subendothelial immune deposits and/or
glomerulonephritis
intramembranous dense deposits, and mesangial
'99er'- Diabetic nephropathy: Its earliest expression is
interposition into the capillary wall, giving rise to a double-
microalbuminuria, which can be seen even in non-
contour or 'tram-track' appearance on light microscopy.
symptomatic patients. This is the rationale for screening
There is marked low complement level. It is associated diabetes patient for microalbuminuria by collecting 24 hour
with Hepatitis C, mycoplasma, etc. urine or using an early morning urine sample (dipstick
use not preferred) to calculate albuminocreatinine ratio.
Focal Segmental Glomerulonephritis Any value < 3.5 or > 10 is abnormal and anything in
It is typically associated with intravenous heroin abuse, between them requires re-evaluation.
morbid obesity, HIV infection. Also seen with reduced ESRD is seen more commonly in black population.
kidney mass like solitary kidney, sarcoidosis, hypertensive
nephrosclerosis, HBV infection. Typically patient is a Clinical Features
young black male with uncontrolled hypertension. Lab All organs systems are affected in ESRD.
tests show microscopic hematuria and biopsy shows Malaise, weakness, and fatigue are very common
capillary tufts. GI disturbances(anorexia, nausea, vomiting, and
hiccups)
Diagnosis Electrolyte abnormalities
Life threatening hyperkalemia
Urine analysis will show massive proteinuria of > 3.5 g/
Dilutional hyponatremia (may cause mental status
day (best test to prove presence of nephrotic syndrome). changes or seizures.)
Other typical lab values, as mentioned in features of Hypocalcemia/hyperphosphatemia (Neuromus-
nephrotic syndrome. cular irritability and secondary hyperparathyro-
Biopsy: Helps differentiate various etiologies of nephrotic idism)
syndrome on basis of histological findings. Hypermagnesemia (neuromuscular depression
with weakness and loss of reflexes).
Treatment Pericarditis and asymptomatic pericardial effusion
Symptomatic treatment by salt restriction, diuretics, statins Hypertension
for lipid elevation, heparin for hypercoagulability is given. Myocardial infarction (accelerated atherosclerosis
seen)
Steroids are mainstay of therapy and various entities
Anemia (due to decreased erythropoietin production)
respond with different degrees of improvement.
Increased bleeding (due to platelet dysfunction)
'99er'- Hematuria: Three or more RBC/hpf on urine
Encephalopathy and neuropathy (due to uremia)
microscopy. First step in management of all patients with
Increased infections (are a leading cause of death and
hematuria is urinanalysis. After that upper tract (kidney, are due to leukocyte dysfunction)
ureter) pathology should be ruled out by intravenous Pruritus [accumulation of toxic pigments (urochromes)
pyelography, CT urogram, and renal ultrasound. Proceed in the dermis]
to cystoscopy, if above investigations are negative. If still Tertiary hyperparathyroidism, with hypercalcemia,
there is no pathology found that is responsible for renal osteodystrophy (osteitis fibrosa) and vascular
hematuria, order a renal angiogram (for varices, calcification develop very late in the disease (Treat
aneurysms). All patients need to undergo a prostate exam with vitamin D, phosphate binders, and calcium
to look for prostatic pathology. replacement).
Nephrology 87
Table 5.7
Renal insufficiency, atherosclerotic Renal parenchymal disease Creatinine clearance, renal ultrasonography
cardiovascular disease, edema,
elevated blood urea nitrogen and
creatinine levels, proteinuria
Use of sympathomimetics, Excess catecholamines Confirm patient is normotensive in absence of high
perioperative setting, acute stress, catecholamines.
tachycardia
Snoring, daytime somnolence, Obstructive sleep apnea Obstructive sleep apnea
obesity
Systolic/diastolic abdominal bruit, Renovascular disease Abdominal ultrasound (best initial), MRA, captopril-
flash pulmonary edema (sudden augmented radioisotopic renography (best non-
left ventricular heart failure) invasive), renal arteriography (overall best)
Decreased or delayed femoral Coarctation of aorta Doppler or CT imaging of aorta
pulses, abnormal chest radiograph
Table 5.8
Stone type Etiology Characteristic Treatment
Calcium oxalate (70%)/ Idiopathic hypercalciuria, In alkaline urine; Hydration, thiazide diuretics
calcium phosphate (10%) primary hyperparathyroidism, radiopaque
vitamin D intoxication
Struvite (Mg-NH4-PO4) Associated with urease producing In alkaline urine; 'triple Hydration; treat UTI if present.
[5-10%] organisms like proteus. phosphate stones'; forms Amenable to percutaneous
stag horn calculi; nephrostomy. Aceto-
radiopaque. Are hydroxamic acid
relatively soft. is an effective urease inhibitor.
Uric acid (5%) In high purine turnover In acidic urine; Hydration; alkalinize urine with
states, gout, hematological radiolucent citrate
malignancy, Crohn's disease
Cystine (1%) Defect in renal transport of Hexagonal crystals; Hydration; pencillamine;
cystine, ornithine, lysine, arginine radiopaque alkalinize urine
cystitis and may present with recurrent hematuria. Most outlet obstruction, urinary retention, urgency, frequency,
common method to diagnose the infection is by demons- hesitancy, chronic renal failure. On digital rectal
trating the parasite and eggs in urine by urinanalysis. examination (DRE) prostate may be felt hard to stony in
consistency.
Table 5.9
-blockers CAD, diastolic CHF, migraine, Heart block, raynaud Systolic CHF, Asthma or
glaucoma, supraventricular phenomenon, bronchospasm, COPD, AV conduction
arrhythmia impotence, fatigue defects, diabetes because it
masks signs of hypoglyce-
mia (relative)
ACE inhibitors CHF, diabetics, post MI (with left Angioneurotic edema, cough*, Bilateral renal artery
ventricular dysfunction) neutropenia, hyperkalemia stenosis, pregnancy
(absolute) anaphylactoid
reactions, taste
disturbances
adrenergic blocker Prostatic hypertrophy, in lipid First dose syncope, headache,
disorder patient dizziness
CCBs Esophageal spasm, raynaud Constipation, heart block, Systolic CHF, AV conduction
phenomenon, angina, supravent- peripheral edema migraine defect (relative)
ricular arrhythmias
* Caused by accumulation of Kinins, possibly due to activation of arachadonic acid pathway. Kinins are degraded by ACE,
but in absence of ACE activity, they increase.
Nephrology 93
6 Respiratory System
PULMONARY FUNCTION TEST (PFT) for the determination of lung volumes. Lung volumes
help in diagnosing and determining the severity of
PFT measures the mechanical function of the lung, chest restrictive lung diseases. Various lung volumes
wall, and respiratory muscles by assessing the total which are measured are:
volume of air exhaled from a full lung (total lung capacity) Tidal volume (TV): Volume of gas breathed in or out
to an empty lung (residual volume). PFTs are used to during normal respiration.
establish baseline lung function and to detect and Expiratory reserve volume (ERV): Additional volume
categorize pulmonary disease into : of gas that can be breathed out after the end
Obstructive diseaseCOPD, asthma, bronchiectasis expiratory level of normal breathing.
Restrictive diseaseobesity, kyphosis, inflammatory Residual volume (RV): Volume of gas remaining in
and fibrosing lung disease, interstitial lung disease. the lungs after forced maximal expiration.
PFTs also help to assess disease severity, monitor Inspiratory reserve volume (IRV): Maximum volume
treatment therapy effects and are also useful in post- of air that can be inspired in addition to the tidal
treatment lung function evaluation. volume.
Vital capacity (VC): Volume of gas exhaled with
PFTs Measure maximal forced expiration.
Static lung compartments: Pulmonary ventilation Total lung capacity (TLC): Volume of gas in the lungs
function needs to be measured under static conditions after maximal inspiration.
Airflow: Here air movement and its flow, in and out of An FEV1/FVC ratio < 70% indicates obstruction
the lungs are measured. Abnormal values of these An FVC < 80% is consistent with restriction
indices point to obstructive lung diseases. Flow rates Forced expiratory flow (FEF 25%-75%)- between 25
that are measured are: and 75% of expiration, also called midmaximal
Expiratory flow rate-ratio of forced expiratory flow rate (MMFR)
volume in 1 second to forced vital capacity (FEV/ Any test value <80% of predicted, is considered
FVC). This ratio is decreased in obstructive abnormal, while>110% of predicted is consistent with air
diseases and increased in restrictive diseases. trapping.
Respiratory System 95
Alveolar membrane permeability: Measured by the caused due to various causes and knowledge about the
diffusing capacity of a gas (DLCO), assesses diseases cause is necessary before treating the hypoxia.
that affect alveolar membrane. Defect in membrane Ventilation-perfusion (V/Q) mismatch:
permeability is seen in all interstitial disease which Respond to oxygen therapy
present with restrictive features as well as PAO2-PaO2 gradient
emphysema, which being an obstructive disease still Seen in asthma, COPD, pneumonia
shows defect in permeability as the disease progresses. Hypoventilation
Responds to oxygen therapy
Table 6.1 Normal PAO2-PaO2 gradient
TLC FEV1/FVC DLco Usually seen in oversedation by medication
Shunt physiology
Asthma Normal Normal to
Typically does not respond to oxygen therapy
COPD Normal to PAO2-PaO2 gradient
Extrathoracic Normal Normal In ARDS, massive pulmonary embolus, patent
restriction ductus arteriosus, patent foramen ovale.
Fibrotic disease Normal to
High altitude
Responds to oxygen therapy
PTFs in Common Diseases Normal PAO2-PaO2 gradient
End Organ Oxygen Delivery Decreased diffusion
May respond to oxygen therapy
Delivery of O2 to organs and tissue depends chiefly on DLco is very low
two factors: PAO2-PaO2 gradient
Cardiac output In interstitial lung disease
Hb level and its saturation In all hypoxic patients, room air O2 saturation of >
This is so because cardiac output determines the 90% and PaO 2 >60 mm of Hg should be tried and
amount of blood being delivered to tissue and Hb is the maintained.
main oxygen delivery vehicle. A small amount of O2 is
also delivered dissolved in plasma. This arterial oxygen CYSTIC FIBROSIS (CF)
tension is measured in terms of partial pressure (PaO2),
which depends on the fractional composition of O2 in It is an autosomal recessive disorder and is the most
inspired air. This dissolved O2 amounts to so small part of common genetic disease in US and in Caucasian
population. It occurs due to mutation in CFTR gene that
total O2 content that there will be minimal change in oxygen
leads to defect in sodium and chloride membrane
delivered to tissue even if patient is given 100% O2.
transport. This defect leads to dysfunction of exocrine
Therefore to ensure proper O2 delivery to tissues in a
glands and also effects cilia and their motion.
critical patient, maintenance of cardiac output and Hb
level to near normal level is very vital.
Clinical Features
Though PaO2 in itself might not be a very useful lab
value, finding the alveolar-arterial gradient (PAO2-PaO2 Patient with CF may present in infancy with meconium
gradient) is a useful calculation in the assessment of ileus or intussusceptions. As patient grows up he may
oxygenation. It is calculated by the following formula: present with recurrent pulmonary infection, chronic/
PAO2-PaO2 gradient = (150 - 1.25 x PCO2) - PaO2 recurrent dry cough that becomes productive later,
In normal young patients it is 5 and 15 mm Hg. It increases sinusitis, hemoptysis, dyspnea on exertion, chest pain,
with all causes of hypoxemia except hypoventilation, as bronchiectasis, features of pancreatic insufficiency like
in morphine overdose and high altitude. malabsorption, steatorrhea, diabetes etc. In adulthood,
males may show aspermia and women have miscarriages.
HYPOXIA Patients are susceptible to pseudomonal and staphy-
lococcal infections.
It is defined as a room air O2 saturation of < 88%/ PaO2 On examination patient shows wheezing, crackles,
< 55 mm of Hg on arterial blood gases (ABG). Hypoxia is failure to thrive and short stature.
96 The Definitive Review of Medicine for USMLE
during this time. Other things that can lead to atelectasis Acute bronchoconstriction
include mucous plug, tumor, or foreign body. Airway edema
Chronic mucous plug formation
Clinical Features Airway remodeling
99er- Cough induced by forced expiration is
In the chronic phase patients may be asymptomatic with characteristic of airway hypersensitivity. Therefore asthma
only X-ray abnormalities, but acutely it may present with is sometimes seen in COPD.
tachycardia, dyspnea, fever, and hypoxemia. Asthma cab be:
Intrinsic /idiosyncratic: Occurs in nonallergic patients
Diagnosis due to non immunologic stimuli such as infections,
Typical history in post operative period points toward exercise, emotional upset, irritating inhalants and cold
atelectasis development. X-ray is very useful modality for air etc. The asthma attacks are severe, and prognosis
the diagnosis. is less favorable.
Extrinsic/allergic/atopic: Occurs because of
sensitization. There is a positive family history of
Chest X-ray
allergic disease. It is precipitated by allergens and
The atelectatic lobe appears to be densely consolidated patient might present with classic atopic triad of
and smaller than the normal lobe on X-ray. In massive allergic rhinitis, wheezing, and eczema. Prognosis is
atelectasis, a mediastinal shift to the involved side can be good.
seen. Many patients have features of both types.
Typical features on X-ray according to lobe Factors that may precipitate an attack of asthma
involvement are: include:
1. Upper lobe: Tracheal deviation to the affected side. Respiratory infections: Especially viral, are the most
2. Lower lobe: Elevation of the corresponding part of the common stimuli to cause asthma attacks. RSV in young
diaphragm. children and rhinoviruses in adults are the major
causes.
Treatment Pharmacologic stimuli: Very important in some cases,
and the most common etiologic agents associated with
Bronchoscopy with subsequent removal of mucous plugs asthma exacerbation are aspirin, -blockers, and
is the treatment of choice for spontaneous atelectasis. It is coloring agents such as tartrazine.
important to induce deep breathing and stimulate Environmental allergens: Like house dust mites,
coughing in post operative phase to prevent atelectasis. animal allergens (especially cat and dog), cockroach
Incentive spirometry, minimal narcotics, early ambulation allergens, and fungi are most commonly reported.
and pulmonary toilet are also effective modalities. Exercise: Exercise can trigger an early asthmatic
To prevent postoperative pulmonary complication in response. Factors that contribute to exercise induced
smokers, smoking should be stopped preoperatively. asthma (EIA) symptoms include the following:
99er- The most common cause of post operative fever Exposure to cold or dry air
in first 24 hour is atelectasis. Duration and intensity of exercise
Coexisting respiratory infection
OBSTRUCTIVE DISEASE Emotional factors: In some individuals, emotional
upsets clearly aggravate asthma.
Asthma Gastroesophageal reflux (GER): The presence of acid
in the distal esophagus, mediated via vagal or other
It is a chronic inflammatory disorder of the airways neural reflexes, can significantly increase airway
characterized by airway hyperreactivity/bronchial resistance and airway reactivity.
hyperresponsiveness and obstruction, which may be Aspirin triad/Samters triad: Some patients suffer from
completely or partially reversed with or without specific aspirin allergy, nasal polyps and asthma, a condition
therapy. It is one of the most common chronic diseases known as the aspirin triad. Aspirin allergy can
worldwide and is the most common cause of hospitaliza- develop later in life, even when previously well
tion of children in the United States. Airflow obstruction tolerated. It usually starts with perennial vasomotor
can be caused by a variety of changes, including: rhinitis; later, asthma appears that occurs with
Respiratory System 99
minimal ingestion of aspirin. There is significant cross 99er-Think of allergic rhinitis in a patient with
reactivity between aspirin and NSAIDs. Patients can chronic cough.
be desensitized by daily administration of aspirin.
Oversecretion of leukotrienes and their activation of Diagnosis
mast cell is the mechanism by which aspirin causes Apart from clinical history, tests used to reach diagnosis
this triad and thats why leukotriene inhibitor are so are:
effective in its treatment. PFTs: Show an obstructive pattern that typically
Nocturnal asthma: During night pulmonary functions reverses with bronchodilation ( in FEV1 or FVC by
are at their lowest level because circulating blood 12% or 200 ml). Sometimes the PFTs may be entirely
levels of epinephrine and cortisol which protect the normal because asthma is reversible and episodic; in
body against asthma are at their lowest levels. this case a provocative challenge may be performed
with methacholine or cold air, which typically shows
Clinical Features a decrease in FEV1/FVC or FEF 25-75% of 20%. A
negative methacholine test excludes asthma. As a
Symptoms of asthma typically may include wheezing, preliminary evaluation for EIA, perform PFTs in all
coughing, shortness of breath and chest tightness. During patients with exercise symptoms to determine if any
an acute episode clinical manifestations vary according baseline abnormalities are present.
to the severity. 99er PFT results are not reliable in patients
Mild: patients may be breathless after physical activity younger than 5 years and in them impulse
such as walking. They can talk in sentences and lie oscillometry system may be used for confirming the
down. Patient has slight tachypnea, tachycardia, diagnosis.
prolonged expirations, and mild, diffuse wheezing Chest X-ray: Flattening of diaphragm with other
and dry cough. nonspecific findings. But it may be helpful in ruling
Severe: Patients are breathless during rest, are not out acute infection as the cause of an acute attack.
interested in feeding, sit upright, talk in words (not Arterial Blood Gas (ABG): In the acute phase typically
sentences), and are usually agitated. Use of accessory show:
muscles of respiration, diminished breath sounds, in pH
loud wheezing, hyper-resonance (increased vocal Normal/PaO2
fremitus), and intercostal retraction are noted in these in arterial PaCO2
severe cases. Very severe asthma may lead to fatigue, In severe asthma or status asthmaticus there will be a
diaphoresis, pulsus paradoxus, inaudible breath PaO2
sounds, decreased wheezing, cyanosis, bradycardia. PaCO2
Presence of these features also indicates poor pH
prognosis. A normal PaCO2 may indicate respiratory muscle
Nocturnal asthma: The majority of these attacks occur fatigue in an acute asthmatic patient. This means that
between midnight and 8 am, peaking on average patient is tiring out and is about to crash.
around 4 am. Patients sometimes presents only with Allergy skin testing: Useful adjunct in individuals with
cough or wheezing. A history of tightness or pain in atopy. Most commonly done by radioaller-gosorbent
the chest may be present with or without other test (RAST)
symptoms of asthma. Such symptoms are also seen in Methacholine- or histamine-challenge testing:
exercise induced asthma. Bronchoprovocation testing with either methacholine
Exercise induced asthma (EIA): Wheezing may be or histamine is useful when PFT findings are normal
present after exercise. Cough, as in nocturnal asthma, or near normal, especially in patients with intermittent
may be the only symptom sometimes. The diagnosis or exercise-induced symptoms.
of exercise induced asthma can be confirmed with the Peak-flow monitoring: It is designed for ongoing
exercise challenge. These patients generally develop monitoring of patients with asthma because the test is
a refractory period, during which a second exercise simple to perform and the results are a quantitative
challenge does not cause a significant degree of and reproducible measure of airflow obstruction. It
bronchoconstriction. can be used for short-term monitoring, exacerbation
99er- Not all that wheezes is asthma: We should rule management, and daily long-term monitoring. Results
out foreign body aspiration, laryngeal spasm/irritation, can be used to determine the severity of an
CHF, GERD, bronchiolitis, cystic fibrosis. exacerbation and to help guide therapeutic decisions.
100 The Definitive Review of Medicine for USMLE
Treatment
Quick relief drugs steroids and as a last resort before using chronic
adrenergic agonist inhalers: Like salbutamol, terbu- systemic steroids.
taline, albuterol are the mainstay of treatment in acute Acute exacerbation of asthma should be treated with:
chronic asthma. Salmeterol (long-acting type of Short acting agonist.
albuterol) is effective in nocturnal cough and exercise- Systemic corticosteroids like methylprednisolone/
induced asthma. Adrenergic agonists must be used prednisone.
with caution in patients who have coexisting
Begin inhaled corticosteroids as well
cardiovascular disorders, hypothyroidism, diabetes
mellitus, hypertension, and coronary insufficiency. Close monitoring with peak flows and adjust therapy
Their most common side effect is tremor. accordingly
Anticholinergic drugs (ipratropium bromide): It is useful 99er- Children with frequent exacerbation: Keep a peak
in cases where adrenergic agonists and theophylline flow meter at home and follow exacerbations with peak
use is not preferred as in heart disease patients. flow measurements. Call physician when values start to
Aminophylline, theophylline: frequently used in acute drop so that early treatment can be initiated.
attacks, though not that effective as short acting
adrenergic agonists. They are sometimes of benefit in CHRONIC OBSTRUCTIVE PULMONARY
chronic management, especially in patients with DISEASE (COPD)
nocturnal cough.
Patients typically have symptoms of both chronic
Long-term control treatment bronchitis and emphysema.
Inhaled corticosteroids are the mainstay of chronic
asthma treatment. Inhaled corticosteroids are Chronic Bronchitis
indicated before oral steroids. Not much useful in EIA.
Patients with chronic bronchitis have productive cough
Side effects of inhaled corticosteroids include oral
for most days of a 3-month period for at least 2 consecutive
candidiasis, weight gain, hypertension, glaucoma,
years.
cataracts, diabetes, muscle weakness, and
osteoporosis.
Emphysema
Mast cell stabilizers (cromolyn sodium, nedocromil):
are first-line chronic treatment in children. Useful for Patients have abnormal permanent dilation of air spaces
EIA treatment and prophylaxis. distal to the terminal bronchioles along with destruction
Leukotriene modifiers(Zileuton): Inhibit 5-lipoxygenase, of cartilage.
the enzyme involved in leukotriene production The shared characteristic of both these condition is
LTD4 receptor antagonists (Zafirlukast and montelukast): their irreversible obstruction of the airway that also sets
In severe asthma resistant to maximal doses of inhaled them apart from asthma.
Respiratory System 101
admit and treat the patient for the low lab values. airways that results from destruction of bronchial elastic
Remember- treat the patient, not the lab values. and muscular elements, most often secondary to an
99er- As a rough rule of thumb and guidelines, prepare infectious process. Any disease that compromises defense
to intubate any patient with PaCO2 > 50 mm of Hg or PaO2 mechanism of lungs like immotile cilia syndrome or cystic
< 50 mm of Hg, especially if pH in either situation is < 7.30 fibrosis and hence predisposes it to recurrent infections
while the patient is breathing room air. lead to a more diffuse kind of bronchiectasis.
99er- Unless patient is crashing rapidly, a trial of 99er-Kartagener syndrome: Ciliary dyskinesia
oxygen by nasal cannula is given first. If the patient is too presenting with situs inversus and sinusitis.
tired or this approach fails, consider intubation.
Clinical Features
Acute COPD Exacerbation
Patient often present with chronic productive cough with
Administer O2 to maintain proper saturation. The goal the sputum being purulent, copious and foul smelling.
is to maintain a PaO 2 of 60 mm Hg, or arterial Patient may also give a history of recurrent pneumonias
saturation of approximately 90%. (especially Pseudomonas), hemoptysis, sinusitis or
Check X-ray to look for causes of exacerbation immune deficiencies. On physical examination there may
Start inhaled adrenergic agonists (albuterol) and be wheezes or crackles.
anticholinergics (ipratropium)
Systemic steroids (prednisone) should be tapered over Diagnosis
3-7 days.
Antibiotics: covering Haemophilus influenza, moraxella Apart from history and examination, hematological studies
and pneumococcus (macrolides/ quinolones). might show secondary polycythemia due to chronic
Continuous positive airway pressure (CPAP) may also hypoxia.
be given if required and possible.
Chest X-ray
Drugs used in Non-emergent COPD No finding in initial course of disease but in later stage
Management Include cysts and typical tram tracking due to crowding of
2-adrenoceptor agonists: Nowadays these are first- bronchi may be seen.
line therapy for COPD, both for acute exacerbations
and for nonacute treatment. Bronchodilators are given High-resolution CT (HRCT)
on an as-needed basis or on a regular basis to prevent It is the best noninvasive test to detect bronchiectasis.
or reduce symptoms.
Anticholinergics (short acting-ipratropium; long Treatment
acting-tiotropium): Have an important role in the acute
treatment of COPD exacerbations. Anticholinergic One of the most important goals in its treatment is to
agents can be used synergistically with adrenergic improve the drainage of bronchi and clear the secretions.
agonists in patients with COPD. Both are preferably It can be achieved by chest physical therapy, postural
given via inhaled route. drainage, and bronchodilators.
Corticosteroids: Inhaled corticosteroids do not have a
major role in long running disease. Antibiotic Therapy
Methylxanthines: No real role in the acute exacerbation During mild symptoms patient can be treated by rotating
of COPD, except to increase the risk of adverse effects. antibiotics amoxicillin, amoxicillin/ clavulanic acid, or
Vaccination: Against pneumococcus every 5 years and trimethoprim sulfamethoxazole. IV antibiotics like
yearly for influenza. Some experts also consider the ceftazidime, quinolones, or aminoglycosides should be
H. influenzae vaccine mandatory. used if patient presents with severe symptoms.
Clinical Features
PNEUMOCONIOSIS
Dyspnea upon exertion is the most common symptom and
These pulmonary diseases are occupational diseases,
worsens as the disease progresses. Patients also have
characterized by nonneoplastic granulomatous and
reduced exercise tolerance, cough and wheezing (espe-
fibrotic changes of the lungs after the inhalation of
cially among smokers), chest wall pain, and ultimately
inorganic substances such as coal dust, asbestos, or silica.
Usually pneumoconiosis appears 20-30 years after may go into respiratory failure. Rales are the most
constant exposure to offending agents. Of all the important finding during examination.
pneumoconiosis, silicosis is the most common in the United Many cancers are associated with asbestos exposure,
States and most often occurs in people working in fields the most common being bronchogenic carcinoma
involving high exposure to dust. History is of primary (adenocarcinoma or squamous cell carcinoma). Pleural or
importance in assessing possible occupational lung peritoneal mesotheliomas are also associated with asbestos
diseases. exposure but are not as common as bronchogenic cancer.
the physical examination findings early in submassive of PE after V/Q scan is low/intermediate. As almost all
PE may be completely normal. Fever, pleuritic chest pain, PEs arise from the proximal veins, these tests are used for
diaphoresis, and cough with or without hemoptysis are the diagnosis of PE before considering the angiogram.
other clinical manifestations of PE along with cyanosis,
loud P2 or S2, JVP, elevated LDH level, and right side Pulmonary Angiogram
failure signs on examination. In young patients, it may be
The angiogram is the gold-standard test to diagnose PE
confused with anxiety attacks and in old, with MI. and should be done in every case in which diagnosis is
99er-Think of PE in a postoperative patient with JVD still not clear even after V/Q scan and Doppler ultrasound.
and new onset RBBB. It is never the first procedure to be performed in diagnosis.
99er-Nitroprusside- abolishes the intrinsic ability of
Diagnosis lungs to match ventilation with perfusion via vasocons-
ABG triction in relatively undeventilated area. Therefore, large
areas of V/Q mismatch are created that result in often
Shows primary respiratory alkalosis and - PAO2-PaO2 profound hypoxia.
gradient. 99er-Sudden onset of shortness of breath with clear
lung is the clue to PE. (Diagnosis clincher).
Chest X-ray 99er-Spiral CT is done if emboli are large and chest
Usually is normal. It may show wedge shaped infarct X-ray is abnormal. In that case its better than V/Q and
(Hamptons hump) and oligemia in affected lobe preferred over it.
(Westermarks sign).
Treatment
ECG Immediate anticoagulation is mandatory for all patients
Will reveal an S wave in lead I, a Q wave in lead III and T suspected to have DVT or PE. Diagnostic investigations
wave inversion in lead III. should not delay empirical anticoagulant therapy. Initial
anticoagulation is performed with intravenous heparin,
Ventilation which slows or prevents the progression of DVT and
reduces pulmonary emboli, but does not dissolve the
Perfusion (V/Q) Lung Scan: This is the first test to do existing clot. The patient should be started simultaneously
when considering the diagnosis of PE. Perfusion scan, on oral anticoagulation with warfarin (on day 1). After a
involving tagged albumin being injected into a patient, therapeutic dose of warfarin is established, heparin is
evaluates perfusion defects. Patients with normal discontinued and warfarin therapy is maintained with
perfusion scans do not have PE and should not be treated. an INR of 2.0-3.0. If PE is highly suspected clinically, and
Ventilation scan, involving inhalation of a tagged gas that X-ray, ABG and EKG rule out other diagnoses, Heparin
is distributed into the airways, scans lungs for ventilation can be started without waiting for V/Q to confirm the
defects. The pretest probability of PE helps determine the diagnosis. In pregnancy give low molecular weight
diagnostic utility of V/Q scans. heparin (LMWH) for 6 months.
In patients with documented large central PE (saddle
High-resolution Multidetector Computed PE) and hemodynamic instability, administer tPA along
Tomographic Angiography (MDCTA) with heparin. If thrombolytic therapy is contraindicated,
Has now been considered as the preferred primary than embolectomy is treatment of choice. Patients with
diagnostic modality and as the standard for making or recurrent PE despite adequate anticoagulant therapy will
excluding the diagnosis of pulmonary embolism. But its need vena caval interruption with a Greenfield vena caval
not widely available, but if available, its to be preferred filter. Although this filter decreases the risk of PE, they are
over V/Q scan as the first modality. associated with higher risk of recurrent DVT.
99er-Warfarin is a vitamin K antagonist that blocks
Doppler Ultrasound formation of clotting factors II, VII, IX, X. Warfarin requires
36-72 h to reach adequate levels for anticoagulation effect
Of the lower extremities are good tests to diagnose lower because although factor VII is decreased first and thus the
extremity DVTs and should be next step when probability PT is elevated, the other factors that may be more important
Respiratory System 107
7 Hematology
ANEMIA along with their heme content. The size is reflected in the
mean corpuscular volume (MCV)
It is defined as a decrease in red blood cell (RBC) mass, Microcytic (<80 fl): Iron deficiency, thalassemia,
when hematocrit (Hct) is <40 in men or <37 in women, or sideroblastosis, and lead poisoning.
hemoglobin is < 14 in men or < 12 in women. Anemia, like Normocytic (80-100 fl): Usually in initial stages of all
fever, is a symptom of disease that requires investigation anemias, hemolytic anemias, and anemia of chronic
to determine the underlying etiology and is not a disease disease (may be normocytic or microcytic).
in itself. Macrocytic (>100 fl): Vitamin B 12 or folic acid
deficiency (most common), also in alcoholism, liver
Classification disease, or due to chemotherapeutic agents
Morphological approach for classification is most popular (methotrexate) or medications (zidovudine,
where anemia is classified by the size of red blood cells phenytoin).
Target cell Hypochromic with central target Liver disease, thalassemia, hemoglobin D,
of hemoglobin postsplenectomy
Leptocyte Hypochromic cell with a normal diameter Thalassemia
and decreased MCV
Elliptocyte Oval to cigar shaped Hereditary elliptocytosis, vitamin B12
and folate deficiency
Tear-shaped RBCs Drop-shaped erythrocyte, often microcytic. Myelofibrosis and infiltration of marrow
with tumor. Thalassemia
Acanthocyte Five to 10 spicules of various lengths and In lipid abnormalities, liver disease
at irregular interval on surface of RBCs.
Echinocyte Evenly distributed spicules on surface Uremia, peptic ulcer, gastric carcinoma,
of RBCs, usually 10-30 pyruvic kinase deficiency, preparative artifact
Sickle cell Elongated cell with pointed ends Hemoglobin S and certain types of
hemoglobin C and I
Hematology 111
Clinical Features
Proper clinical history and physical examination of each
anemic patient helps a lot to reach the exact etiology of
anemia. The severity of symptoms is very much related
to the underlying health of the patient. Patient usually
presents with fatigue, poor exercise tolerance, tiredness
with dyspnea and lightheadedness on exertion is severe
disease. As disease progresses he may present with
confusion and altered mental status and eventually death
may occur because of MI, if anemia is not corrected in
Fig. 7.2: Schistocytes (For color version see Plate 1) time. On examination patient has pallor, tachycardia,
and a systolic ejection murmur (in moderately severe
anemia).
Diagnosis
Initially, order a complete blood count (CBC), MCV,
peripheral blood smear, reticulocyte count, iron studies
(serum iron, ferritin, TIBC), serum folate, vitamin B12, TSH,
hemolysis labs (unconjugated bilirubin, haptoglobin,
Coombs test, LDH), DIC panel (fibrinogen, D-dimer). Keep
an eye if pancytopenia is there.
Fig. 7.3: Howell-Jolly bodies (For color version see Plate 1) Treatment
Fluid resuscitation and RBC transfusion are mainstay of
treatment for severe anemia. Transfusion should be done
to ensure Hb> 9 mg/dL (> 8 mg/dL for CAD patient). But
transfusion should be more of based on clinical grounds
and not on lab values, like an asymptomatic patient whose
Hb on routine examination is found out to be 7 mg/dL do
not require an immediate transfusion.
MICROCYTIC ANEMIA
Iron Deficiency Anemia
Iron deficiency anemia occurs when iron deficiency is
Fig. 7.4: Typical sickle cell (For color version see Plate 1) sufficiently severe to diminish erythropoiesis. Iron
112 The Definitive Review of Medicine for USMLE
deficiency is the most prevalent single deficiency state and recur. Parenteral iron should be given to patients with
the most common anemia on a worldwide basis. The most malabsorption, very high iron requirements, and in those
common cause of iron deficiency anemia is blood loss from who cannot tolerate oral therapy.
the body, either acute or chronic (in GI or menstrual bleed). 99er: Elderly person with microcytic anemia- suspect
Other causative factors may be poor oral intake, intake of colorectal carcinoma and refer the patient for a colonoscopy.
substances that decrease absorption of non heme iron like
phytate, phosphates, etc. and malabsorption (absorbed MICROCYTIC HYPOCHROMIC ANEMIAS
mostly in duodenum).
Thalassemia
Clinical Features They are inherited disorders of Hb synthesis, with defect
Though it is a lab diagnosis, history of hemorrhage, pica, in production of either the alpha or beta globin chains.
and vegetarian with no iron supplement point towards The imbalance created by decrease in the rate of production
of a certain globin chain/chains ( , , , ) is the hallmark
iron deficiency as cause of anemia. Usually patient presents
of all forms of thalassemia.
with symptoms mentioned above for general anemia. Some
signs that are specific to iron deficiency, though rarely
Classification and Clinical Features
seen, are brittle nails, spoon shaped nails koilonychia
(diagnosis clinchers), and glossitis. Plummer-Vinson The presentation is based on the severity of gene deletion.
syndrome constitutes iron deficiency anemia, esophageal Alpha thalassemia: There are four genes coding for the
webs, and glossitis. alpha chain of hemoglobin. It is more common in Asian
populations.
Diagnosis Silent carrier Thalassemia: Subclinical thalassemia;
one of the genes is absent. Patients are hemato-
A low serum iron and ferritin with an elevated TIBC logically healthy, except for occasional low RBC
are diagnostic of iron deficiency. While a low serum indices.
ferritin (<10 ng/ml) is virtually diagnostic of iron thalassemia trait: Typically caused by the deletion
deficiency and is most useful test, a normal serum ferritin of 2 gene. This trait is characterized by mild anemia
can be seen in patients who are deficient in iron and and low RBC indices.
have coexistent diseases (hepatitis, anemia of chronic HbH disease: Results from the deletion or inactivation
disorders). The red cell distribution width (RDW) is of 3 globin genes. It represents thalassemia
elevated. The reticulocyte count is low. The most specific intermedia, with mild to moderately severe anemia,
test is a bone marrow biopsy. splenomegaly, icterus, and abnormal RBC indices.
thalassemia major (Hb barts): This condition is the
Treatment result of deletion of all four genes, leading to the severe
The iron deficiency should be treated with oral iron therapy form of homozygous thalassemia, which is usually
(ferrous sulfate tablets) for 3-6 months, and the underlying incompatible with life and results in hydrops fetalis,
etiology should be corrected so the deficiency does not unless intrauterine blood transfusion is given.
Table 7.3
Conditions Serum Iron Serum ferritin Total iron-binding Bone marrow Comments
capacity (TIBC) iron
Iron deficiency 0 Responsive to iron therapy
Chronic inflammation N- N- ++ Unresponsive to iron therapy
Thalassemia major N- N ++++ Reticulocytosis and indirect
bilirubinemia
Thalassemia minor N N- N ++ Elevation of A fetal
hemoglobin, target cells, and
poikilocytosis
Lead poisoning N N N ++ Basophilic stippling of RBCs
Sideroblastic N ++++ Ring sideroblasts in marrow
Hematology 113
Diagnosis Diagnosis
Peripheral film shows a microcytic anemia with normal Usual lab findings are:
iron studies. Hemoglobin electrophoresis tells which type Increased/normal ferritin levels
of thalassemia is present. In thalassemia, there is an Decreased TIBC.
increased level of hemoglobin F and hemoglobin A2. Hematocrit of about 20-30%
Those with thalassemia will have normal amounts of Serum Iron: High
hemoglobin F and A2. Unlike thalassemia trait, thalasse- High transferring saturation
mia major is associated with a markedly elevated RDW, The most specific test is a Prussian Blue stain of red
reflecting the extreme anisocytosis. Target cells are present blood cells in the marrow that will reveal the ringed
in all forms of thalassemia. sideroblasts (Diagnosis clincher).
Lead poisoning shows basophilic RBC stippling and
Treatment elevated free erythrocyte protoporphyrin (diagnosis clincher).
Treatment Diagnosis
Correct the underlying disease. Epogen (recombinant Characteristically red cells are macro-ovalocytes; unlike
erythropoietin) should also be administered. round macrocytes of liver disease or myelodysplasia.
99er-In presence of acute bacterial infection, anemia Hematological tests of both B12 deficiency and folic acid
of chronic disease can be difficult to differentiate from Fe deficiency give same picture. Pancytopenia may be seen.
deficiency anemia and in such situation bone marrow The reticulocyte count is reduced, although the bone
biopsy is best diagnostic test. marrow is hypercellular. Some other nonspecific findings
are an elevated LDH, bilirubin, and iron levels. Two
MACROCYTIC ANEMIA finding that can distinguish both these condition include
the specific test of serum vitamin B 12 level and
Megaloblastic Anemia
methylmalonic acid level (elevated in B12 deficiency). The
It is characterized by nuclear dysmaturity, where the Schilling test is occasionally used to determine the etiology
nucleus appears immature relative to the cytoplasm of vitamin B12 deficiency.
because of impaired DNA synthesis.
The 2 most common causes of megaloblastic anemia Treatment
are vitamin B12 deficiency (cobalamin) and folinic acid
deficiency. Although their clinical settings differ Parenteral therapy particularly by the intramuscular route
considerably, no hematologic finding can distinguish is preferred therapy for replacement. Monthly B12 shots
between the 2 conditions. Other causes include alcohol, may be used. Folic acid replacement can correct the
liver disease, myelodysplasia, the use of metabolic hematologic abnormalities of B12 deficiency, but not the
inhibitors such as methotrexate and 6-mercaptopurine and neurologic abnormalities.
certain rare inborn errors such as Lesch-Nyhan syndrome 99er-Pernicious anemia: Anti intrinsic factor antibody
and hereditary orotic aciduria. is initial test of choice. Rugae are usually absent in
pernicious anemia, with exception at gastric antrum where
Vitamin B12 Deficiency they are normal.
It is most commonly seen in pernicious anemia, a
hereditary, autoimmune disorder resulting in decreased Folic Acid Deficiency
intrinsic factor production (also in gastrectomy and It is usually due to decreased dietary intake and clinically
atrophic gastritis). Impaired transport from intestine due usually seen in alcoholic and pregnant persons.
to malabsorption (as in sprue), pancreatic insufficiency, Occasionally skin loss in diseases like eczema, increased
and tapeworm infection with Diphyllobothrium latum
loss from dialysis, or drugs like trimethoprim, phenytoin,
can also cause deficiency. Phenytoin administration can
and methotrexate may also account for the deficiency.
also be an important cause as it acts like an antimetabolite
of folic acid.
Clinical Presentation
99er-Pernicious anemia: patient with primary
hypothyroidism may develop pernicious anemia. As described above.
Hematology 115
Diagnosis Diagnosis
Definitive diagnosis is based on a low red blood cell folic An increased reticulocyte count is a criterion for hemolysis,
acid level. but is not specific for it. Increased reticulocyte count with
normal hemolysis labs is indicative of hemorrhage. The
Treatment LDH and indirect bilirubin (seldom > 4) are elevated. Lab
features typical of intravascular hemolysis are mentioned
Oral replacement of folinic acid. above.
99er-Treatment of megaloblastic anemia may lead to
development of hypokalemia because of uptake of K+ by Treatment
newly forming cells. Therefore monitor potassium level in
Patient who suffers with an acute attack of hemolysis
first 48-hour of treatment of moderate/severe
should be hydrated well enough to prevent toxicity to the
megaloblastic anemia.
kidney tubule from the free hemoglobin. Proper hydration
is of utmost importance in acute hemolysis attack.
HEMOLYTIC ANEMIA Adequate red cell transfusion should also be considered.
Hemolysis is the premature destruction of erythrocytes,
and this hemolysis leads to anemia when bone marrow Sickle Cell Disease (SCD)
activity cannot compensate for the erythrocyte loss. Sickle cell anemia is an autosomal recessive inherited blood
Hemolysis may be either intravascular or extravascular. disorder characterized primarily by chronic anemia and
In intravascular hemolysis, RBCs lyse in the circulation periodic episodes of pain. RBC are sickle shaped and their
releasing hemoglobin into the plasma. Causes include stacking up in the small blood vessels lead to distal
prosthetic cardiac valves, G-6-PD deficiency, thrombotic ischemia and episodes of pain, which increases in times
thrombocytopenic purpura, disseminated intravascular of hypoxia, dehydration, infection, fever, or acidosis.
coagulation, and paroxysmal nocturnal hemoglobinuria SCD can be in heterozygous form (trait) or homozygous
(PNH). Its characteristics are: (disease), form with heterozygous usually being
Fragmented RBCs (schistocytes). asymptomatic. SCD is very common in black population.
serum haptoglobin (due to bonding of Sudden drop in hematocrit can be due to acute bone
hemoglobin released in blood with serum marrow aplasia like in folate deficiency or parvovirus
haptoglobin) [diagnosis clincher]. B19 (common in day care in children),or increased
Hemoglobinuria (when serum haptoglobin is not hemolysis due to concomitant G6PD deficiency.
enough to bind all the hemoglobin or the release is
rapid enough) Clinical Features
Hemosiderinuria (in chronic intravascular The presenting symptoms of SCD involve pain and
hemolysis) anemia.
unconjugated bilirubin Childhood and adolescence:
LDH growth retardation
In extravascular hemolysis, RBCs are phagocytized delayed sexual maturation
by macrophages in the spleen and liver. Causes include underweight
RBC membrane abnormalities such as bound immu- Adults: The most common clinical picture in adults is
noglobulin, or physical abnormalities restricting RBC vasoocclusive crisis, which appear suddenly and may
deformability and preventing egress from the spleen like present as:
hereditary spherocytosis or sickle cell anemia. Extremities and long bones pain
Extravascular hemolysis is characterized by spherocytes. Abdomen: severe pain resembling acute abdomen
Acute chest syndrome: resembeling pneumonia, consists
Clinical Features of severe chest pain, fever, leukocytosis, hypoxia, and
Hemolytic anemia is most common cause of sudden onset infiltrates on the chest X-ray.
anemia (excluding blood loss from body). This type of Stroke and TIA.
anemia is usually associated with dark urine and jaundice. Priapism: from infarction of the prostatic plexus of
Rapid intravascular hemolysis is also associated with veins.
fever, chills, chest pain, tachycardia, and backache. Blindness: by retinal vein occlusion.
116 The Definitive Review of Medicine for USMLE
It is caused usually by viral illness or E. coli O157:H7. acid (in mucosal bleeding) and platelet transfusion (in
As compared to TTP, CNS is not involved in HUS and is surgery or life-threatening hemorrhage).
more common in children. 99er-Glanzmann Thrombastheniaplatelet GPIIb/
99er-Essential thrombocythemia- is seen mostly IIIa complex is either deficient or dysfunctional leading to
between 50-70 years of age. Platelet count may reach up to defective platelet aggregation and subsequent bleeding.
a million and is characterized by platelet aggregates, giant Platelets are grossly normal. Primary platelet aggregation
platelets, and megakaryocytic fragments on peripheral response to platelet agonists ADP, epinephrine, and
smears. collagen are decreased, while the response to ristocetin is
normal. Treatment in patients that have bleeding is platelet
Von Willebrand Disease (VWD) transfusion. Consider oral contraceptives to control
menorrhagia.
It is platelet-type bleeding due to an abnormality, either
quantitative or qualitative, of the VWF (a large multimeric
COAGULOPATHY
glycoprotein) that functions as the carrier protein for factor
VIII and is also required for normal platelet adhesion to It is a condition in which defective clotting cascade predis-
endothelial lining of blood vessel. VWD is the most poses patient to bleeding. A history of recurrent
common hereditary bleeding disorder and is inherited by spontaneous bleeding suggests a coagulation factor
autosomal dominant transmission. deficiency. Two tests that are commonly used to diagnose
and differentiate various coagulopathies are prothrombin
Clinical Features time (PT) and partial thromboplastin time (PTT).
Patient presents with platelet type bleeding, same as the PT and normal PTT: Seen in liver disease, warfarin
way described in ITP. use, vitamin K deficiency and early DIC. Check factor
VII level, once these conditions are excluded.
Diagnosis Normal PT and PTT: Usually seen during heparin
therapy. If patient is not on heparin, a 50:50 mixing
The platelet count and appearance are normal. The
study of mixing patient serum with normal serum
bleeding time is increased. The level of von Willebrand
should be ordered.
factor, also known as factor VIII antigen, is low. The
PTT normalizes: Either of factor VIII, IX, XI deficiency
ristocetin platelet aggregation test is abnormal, but is
PTT doesnt normalize: Factor VII inhibitor present
corrected upon addition of normal plasma. The PTT may
be elevated in some patients because of a concomitant or antiphospholipid syndrome
decrease in levels of factor VIII coagulant portion, but it is PT and PTT: Seen in severe liver disease, severe
usually a lab artifact and does not result in the heme- vitamin K deficiency, warfarin overdose, heparin use
arthrosis and hematomas characteristic of clotting factor and severe DIC. Once these conditions are excluded,
type bleeding. check for deficiency of factor II, V, and X.
99er-Antiphospholipid syndromeis characterized
Treatment by prolongation of PTT, but surprisingly these patients
are prone to thrombosis rather than bleeding and the
Desmopressin acetate (DDAVP) is used for mild bleeding prolongation is due to an in vitro reaction of antibodies
or when the patient must undergo minor surgical with phospholipids present in reaction test. This
procedures. Desmopressin releases subendothelial stores propensity to cause thrombosis in veins and arteries may
of von Willebrand factor. Cryoprecipitates may also be cause fatal cerebral, myocardial and intestinal infarction.
used. Specific von Willebrand factor replacement is very It is associated with SLE and lupus anticoagulant and
good treatment modality available now. anticardiolipin antibody should be ordered. This syn-
99er-Bernard-Soulier syndrome is characterized by drome causes repeated miscarriages.
thrombocytopenia, large platelets, and tendency toward 99er-Vitamin C deficiency- is seen commonly in
bleeding. BT is prolonged and platelets do not aggregate people who live on toast, tea and sodas. The deficiency
in response to ristocetin, which is not even corrected by causes scurvy. Patient has petechiae and splinter
the addition of normal plasma (as seen in VWD). Platelets hemorrhages under finger nails. Platelet and coagulation
have normal aggregation in response to ADP, epinephrine, studies are all normal. Management includes oral
and collagen. Treatment involves epsilon aminocaproic vitamin C therapy and an appointment with dietician.
120 The Definitive Review of Medicine for USMLE
Table 7.4
Coagulopathy Platelet disorder
Time of bleeding onset after injury Delayed. Spontaneous in joints/hematomas Immediate
Bleeding upon surface cuts Almost normal Excessive and prolonged
Clinical features Bleeding in deep structures like joints, Superficial, mucosal bleeding.
muscles, GIT, genitourinary tract Petechiae and ecchymosis often
present.
PT/PTT Either or both prolonged Normal
Platelet count/ BT Usually normal Count and BT prolonged
Table 7.5: Comparison of coagulopathy and platelet VIII. Hemophilia B and more severe hemophilia A require
disorders specific factor replacement.
Disease Platelet BT PT PTT RBC
count count Vitamin K Deficiency
Hemophilia A/B N N N N It results in decreased production of factors II, VII, IX, and
VWD N N N X and is seen due to dietary deficiency, malabsorption,
Liver disease N/ N N/ and the use of antibiotics that kill colonic bacteria that
DIC N/ produce vitamin K.
Heparin N/ N N N
Warfarin N N N N Clinical Features
ITP N N N
Venapuncture oozing is seen along with the presentation
TTP N N
seen in hemophilias.
Diagnosis Diagnosis
Peripheral smears: Shows normochromic, normocytic Total serum protein is elevated which followed by serum
anemia. protein electrophoresis (SPEP) shows an elevated mono-
Lab tests: Hypercalcemia, elevated BUN, creatinine. clonal immunoglobulin spike. Bone marrow examination
Urinanalysis- proteinuria due to multiple myeloma is shows < 5% plasma cells.
not detected by urinanalysis.
Whole body X-ray: Reveal the punched out lytic lesions. Treatment
Protein electrophoresis: Markedly elevated monoclonal No treatment required.
immunoglobulin (IgG or may be IgA, IgD).
Bone marrow biopsy: >10% plasma cells confirm Hodgkin Disease
multiple myeloma.
24-hour urine collection: For quantification of It is a potentially curable malignant lymphoma with dis-
proteinuria is useful for diagnosis (>1 g of protein in tinct histology, biologic behavior, and clinical charac-
24 h is a major criterion) and for monitoring the teristics, which involves neoplastic transformation of lym-
patients response to therapy. phocytes particularly; in the lymph node. Infectious agents,
Urine protein electrophoresis: Detects presence of the particularly the Epstein-Barr virus (EBV), may be involved
Bence Jones protein (lambda light chains) in urine. in the pathogenesis of Hodgkin disease. Patients with HIV
126 The Definitive Review of Medicine for USMLE
infection have a higher incidence of Hodgkin disease A or B designations denote the absence or presence of
compared to the population without HIV infection. B symptoms respectively.
Hodgkin disease has several histologic subtypes. Now IA and IIA are managed with radiation. All
Lymphocyte-predominant has the best prognosis, and patients with evidence of B symptoms are also treated
lymphocyte-depleted has the worst prognosis. with radiation therapy.
Stage III or Stage IV disease are managed with
Clinical Features chemotherapy. The most effective chemotherapy is
Patient commonly presents initially with cervical, adriamycin (doxorubicin), bleomycin, vinblastine, and
supraclavicular, and axillary lymphadenopathy, which dacarbazine (ABVD).
are characteristically painless, rubbery, nonerythematous, 99er-EBV infection is a common cause of aggressive
and nontender. Alcohol-induced pain at sites of nodal lymphoma in patients who already have congenital or
disease is specific for Hodgkin disease (in 10% patients) acquired immune deficiency.
[diagnosis clincher]. Patients also presents with fever,
drenching night sweats, >1/10th of weight loss (all 3
Non-Hodgkin Lymphoma (NHL)
called B symptoms), pruritis, cough or breathlessness. NHL is not a single entity but is instead a diverse group of
Extra lymphatic involvement may be present but is more cancers differentiated on the basis of cell type and involves
common with non-Hodgkin lymphoma. the neoplastic transformation of both the B (majority) and
T cell lineages of lymphatic cells.
Diagnosis NHL involves lymph nodes but lymphatic organs
CBC shows anemia, increased WBC (eosinophilia), involvement is move common. There are no specifically
platelets. Elevated ESR and LDH levels are prognostically known etiological factors for development of NHL.
significant. A histological diagnosis is always required Infections that are associated with NHL development
and can be the initial test when clinical suspicion is high. include HIV, Epstein-Barr (both associated with Burkitt
An excisional lymph node biopsy is recommended lymphoma), HTLV-I, and Helicobacter pylori.
because the lymph node architecture is important for Immunosuppressed patients like the ones who underwent
histological classification. Once diagnosis is confirmed, bone marrow transplantation are also predisposed to
whole body X-ray, chest and abdominal CT, or MRl are develop NHL.
used to determine if the disease is localized to the
supraclavicular area or not. A staging laparotomy is used
Clinical Features
to definitively exclude more widespread disease if these The clinical presentation is almost similar to HD and so is
investigations are doubtful. the staging system, but for one fact that NHL
predominantly affects extralymphatic tissue as compared
Treatment to localized lymphatic involvement in HD. HIV positive
Therapy is based on the stage of the disease. Ann Arbor NHL patient often have CNS involvement.
classification is used most often for staging.
Diagnosis
Stage I denotes involvement of a single lymph node
area or single extranodal site. Excisional lymph node biopsy is mainstay of diagnosis
Stage II denotes involvement of 2 or more lymph node of NHL. Lab tests give results almost similar to HD. Due to
areas on the same side of the diaphragm. significant extra lymphatic involvement, chest X-ray,
Stage III denotes involvement of lymph node areas on ultrasound, CT scan and bone marrow biopsy are done
both sides of the diaphragm. for staging. Immunological markers are required to
Stage IV denotes involvement of disseminated differentiate different types of NHL.
or multiple involvement of extranodal organs.
Involvement of the liver or the bone marrow is Treatment
considered stage IV disease. For staging classifications The protocol of staging and treatment is similar to HD.
the spleen is considered to be a lymph node area. The initial chemotherapeutic regimen of choice is CHOP
Involvement of the spleen is denoted with the suffix S (cyclophosphamide, hydroxy-adriamycin, oncovin
(IIBS). [vincristine], prednisone). CNS lymphoma is usually
Hematology 127
treated with radiation, possibly in addition to CHOP. NHL acute swelling), porphyria cutanea tarda (chronic
relapses can be controlled with autologous bone marrow blistering skin lesions).
transplantation. A new drug Rituximab (an anti-CD20 99er-Tachycardia and hypotension are signs of
antibody) is used in NHL cases that express CD20 and is moderate to severe hemorrhage and no delay should be
said to be very effective. done in instituting fluid therapy and regardless of etiology
99er-Tumor lysis syndrome- presents with hyper- any patient with active bleeding and marginal vital signs
kalemia, hyperphosphatemia, hyperuricemia, and hypo- should at least be given 3 L of crystalloid fluids like normal
calcemia. saline or ringer lactate.
99er-Decraeased metabolization of citrate in
99er-Fresh frozen plasma (FFP)increases plasma
transfused patients (due to various reasons including
anticoagulation factors and is given in chronic liver
hypothermia) may result in renal and hepatic failure,
disease.
hypothermia, and shock. These patients also have high-
Washed RBCs are free of traces of plasma, WBCs, and
risk of hypocalcemia, even though total calcium may be
platelets. This is useful in IgA deficiency patients and
normal. This is because of decrease in ionic calcium.
Therefore for every 500 ml of blood transfused, 10cc of allergic or previously sensitized patients.
10% calcium gluconate must be given. Cryoprecipitate is prepared from FFP and contains
99er-Mastocytosis- presents with sclerotic bone lesion, concentrated factor VIII, XIII, fibrinogen, and von
diarrhea, eosinophilia, ulcer disease, GI bleed. Willebrands factor. Its use is indicated in DIC, hemophilia
99er-Porphyrias- are defect in heme synthesis. The A and von Willebrands disease.
most common forms are - acute intermittent porphyria (has Packed red cells are prepared from all the red cell mass
neurovisceral symptom with abdominal pain being very in a pint of donated blood. It has no plasma and no proteins.
common), erythropoietic protoporphyria (painful skin and Indicated to restore red cell mass.
Chapter
8 Gastroenterology
ESOPHAGUS DISORDERS Chest x-ray: may show an air-fluid level in the dilated
esophagus
Dysphagia: is difficulty swallowing (Table 8.1).
Esophageal manometry: is the most accurate test.
Odynophagia: is pain on swallowing.
Endoscopy: may be done to rule out carcinoma.
Achalasia
Treatment
It is an esophageal motor disorder characterized by
CCBs, nitrates may be used but benefit small proportion of
increased lower esophageal sphincter (LES) pressure,
patents. Intrasphincteric injection of botulinum toxin may
diminished-to-absent peristalsis in the distal portion of
be used but treatment of choice is pneumatic dilation
the esophagus, and lack of a coordinated LES relaxation
especially in those cases in which surgery is not
in response to swallowing. This occurs due to loss of
appropriate. Surgical procedure of choice is laparoscopic
inhibitory neurons, which normally upon stimulation
block the impulse that causes constriction. It is associated Heller myotomy but it may cause an increase in reflux
with lacrimal secretory disorders and adrenal incidences.
insufficiency. It is usually an idiopathic disorder with few
cases being caused by Chagas disease or lymphoma that
Esophageal Cancer
infiltrates LES region. Squamous cell carcinoma: in proximal two-third of
esophagus and associated with alcohol and tobacco.
Clinical Features Adenocarcinoma: in distal one-third and associated
Progressive dysphagia (most common symptom- to with gastroesophageal reflux and Barrett esophagus.
both solids and liquids simultaneously)
Regurgitation Diagnosis
Chest pain Barium swallow: is usually the first and very sensitive
Weight loss test for helping detect stricture and intraluminal
masses.
Diagnosis Endoscopic ultrasound: is the most sensitive test to help
Barium esophagography: is the initial test done and it determine the depth of penetration of the tumor
shows dilation of the esophagus, narrowing into a (T staging) and the presence of enlarged periesopha-
"bird's beak" at the distal end (diagnosis clincher). geal lymph nodes (N staging).
Endoscopy: is must to get a biopsy of the lesion. immunocompromised or diabetics), radiation exposure,
Abdominal and chest CT scans: are useful to help or direct erosive effects of ingested drugs (iron, potassium,
exclude the presence of metastases (M staging) and alendronate, quinidine, aspirin, steroids, tetracyclines,
local spread. NSAIDs). Most common infectious agent is Candida (in
HIV positive when CD4 < 200/mm3) and rarely HSV or
Treatment
CMV
Chemotherapy with 5-fluorouracil combined with
radiation is used in patients who are not candidates of Clinical Feature
surgery. The truly effective therapy for esophageal
Odynophagia is a common presenting complaint with
carcinoma is surgical resection if it is localized.
rarely being accompanied by dysphagia.
Esophagitis Diagnosis
It is either inflammation or infection of esophagus. It is History of any toxin ingestion may be important in reaching
usually caused by reflux disease, infection (mostly in the diagnosis. Perform a double-contrast esophageal
Systemic sclerosis Due to atrophy and Dysphagia along with reflux Motility study-LES neither Metoclopramide, erythro-
fibrosis of esophageal (diagnosis clincher) relaxes nor contracts mycin (promotility drug).
smooth muscles (like an immobile open Proton pump inhibitors
tube) (PPIs) also used.
Esophageal spasm Idiopathic. Both essentally Intermittent dysphagia and Barium studies CCBs or nitrates relieve
/nutcracker disease same except manometric chest pain [no relation with (corkscrew pattern); symptoms
finding difference food, precipitated by cold manometric study (most
liquids (diagnosis clincher)] accurate)-high intensity
(in nutcracker), disorga-
nized contractions (in spasm)
Rings and webs Schatzki's ring and Schatzki's ring (distal location) Barium esophagogram Dilation procedure. Plum-
plummer-vinson syndrome -intermittent dysphagia, no mer-Vinson syndrome
thin epithelial membranes. pain. Plummer-Vinson also responds to correc-
Both non progressive. syndrome (proximally; tion of Fe deficiency.
associated with Fe deficiency
anemia)-sometimes dysphagia
with liquids also
Zenker's diver- Outpouching of posterior In old age. Difficulty initiating Barium study Surgical resection. Endo-
ticulum pharyngeal constrictor. swallow, bad breath, repeated scopy or NG tube place-
Very slow developing. throat clearing, throwing up ment contraindicated
food eaten few days back
(diagnosis clincher)
130 The Definitive Review of Medicine for USMLE
barium study as a first-line test, if dysphagia is a primary clinical presentation usually consists of repeated episodes
complaint, to rule out other pathologies. of retching and vomiting, typically in a middle-aged man
with recent excessive dietary and alcohol intake. It is
Treatment followed by a sudden onset of severe chest pain in the
In HIV positive, response to fluconazole is diagnostic and lower thorax and upper abdomen that may radiate to the
therapeutic. If it doesn't work then endoscopy is indicated. back or left shoulder and is typically aggravated by
Drugs that cause esophagitis should be taken in upright swallowing. Usually, hematemesis is not seen after
position with lots of water as a precaution against esophageal rupture, which helps distinguish it from the
developing esophagitis. more common Mallory-Weiss tear.
Perform imaging studies to stage and localize the or spreads proximally and contiguously. The small
gastrinoma. intestine is never involved, except when the distal
Determine if patient is a surgical candidate for tumor terminal ileum is inflamed in a superficial manner
resection. referred to as backwash ileitis.
Elevated serum calcium levels should prompt a Crohn's disease (CD)
search for MEN 1 syndrome. Presentation of CD is generally more insidious than
that of UC, with ongoing abdominal pain, anorexia,
Treatment diarrhea, weight loss, and fatigue.
The most typical manifestations are abdominal pain
In acutely ill, immediate control of gastric acid and diarrhea. Pain is particularly common, especially
hypersecretion can be achieved with IV PPIs. All patients when some degree of obstruction is present. Its colicky
with sporadic ZES without hepatic metastases or medical and classic location is right lower quadrant
contraindications to surgery should undergo surgical (appendicitis like).
resection. For patients with metastatic disease CD is more likely to be associated with a palpable
chemotherapy, interferon, and octreotide may be helpful. abdominal mass because CD has granulomas in the
'99er'- Menetrier disease- is characterized by markedly bowel wall that are transmural in nature, which can
thickened gastric folds. It may lead to decreased acid lead to the different loops of bowel being inflamed
secretion, weight loss, and a protein loosing enteropathy and sticking together, forming a mass. These masses
leading to edema. There is no specific medical treatment can be palpated and cause pain.
and most patients require partial or complete gastric Weight loss is observed more commonly in CD than
resection. in UC because of the malabsorption associated with
small bowel disease.
Inflammatory Bowel Disease (IBD) Patient sometimes may also experience fecal
It commonly refers to Ulcerative colitis (UC) and Crohn's incontinence with small amount of stools.
disease (CD), which are idiopathic, chronic inflammatory Extra intestinal manifestations of IBD are:
diseases of the GI tract, probably involving immune system. Arthritis: The axial arthritis consists of ankylosing
The presentation, diagnostic work up and treatment of spondylitis and sacroiliitis. Axial arthritis is often
both these condition is quite similar. associated with HLA-B27. The peripheral arthritides
is a nondestructive arthritis, which is typically
Clinical Features asymmetric, and affects large weight-bearing joints.
Eye: episcleritis and iritis (uveitis) are seen in UC.
Both UC and CD usually have waxing and waning Treatment of these complications often requires high-
intensity and severity. When the patient is actively dose systemic steroids or infliximab.
symptomatic, indicating significant inflammation, the Skin:
disease is considered to be in an active stage and the patient Erythema nodosum: It usually dissipates with bowel
as having a flare of the IBD. Both usually present with disease treatment.
fever, diarrhea, weight loss, fatigue, anemia and, Pyoderma gangrenosum: Starts as an inflamed patch
occasionally abdominal pain and bleeding. Both forms of of skin ranging from one to several centimeters in
IBD can lead to colon cancer after 8 to 10 years of diameter that progresses until it ulcerates. Upon
involvement of the colon, more so in UC. ulceration, the lesion may persist for many months
Typical presentation of each condition is as follows: before healing. Treatments that have been tried
Ulcerative colitis (UC) include dapsone, metronidazole, cyclosporine,
The most typical manifestation is bloody diarrhea and infliximab.
(with urgency). Pain is uncommon but if occurs, its Urinary complications: More common in persons with
cramping. CD. Calcium oxalate stones are the most common type
Usually occurs in young females. of renal calculi associated with CD. Treatment is to
UC is limited exclusively to the large bowel and is increase hydration and to use oral calcium citrate
exclusively a mucosal disease. UC has no skip lesions, supplements, which bind the oxalate within the
no fistula formation, and no oral or perianal intestinal tract and prevent its excretion in the urinary
involvement like CD. It remains confined to the rectum tract. Because of its proximity to the ureters,
134 The Definitive Review of Medicine for USMLE
inflammation of the small bowel may involve the relief of symptoms and a significant decrease in
ureters causing obstruction and hydronephrosis. inflammation. If IBD is refractory to corticosteroid therapy,
Fistulae occasionally occur between the bowel and or have frequent flares that require corticosteroid therapy,
bladder or ureters. the third step for medication is one of the immuno-
Sclerosing cholangitis: is most commonly associated modulator (6-MP or azathioprine). Infliximab is used in
with UC and should be aggressively sought when refractory disease or in CD patients who form fistulae.
abnormal LFT results of cholestatic pattern are found Patient should also undergo serial imaging to rule out
in a patient with ulcerative colitis. Colonoscopy is perforation, megacolon, or abscess development in CD.
indicated, if sclerosing cholangitis is diagnosed in UC patient should undergo colonoscopy 8-10 years after
the absence of a known history of ulcerative colitis. diagnosis and then annually thereafter because incidence
Gallstones: are common in persons with CD, but these of colon cancer in UC is 1% every year after 10 years of
persons are usually asymptomatic; occasionally disease.
cholecystectomy is necessary. Long term treatment therapy of IBD involves
Anemia: associated with IBD which may be of 2 types mesalamine derivatives (sulfasalazine in old times) as
iron deficiency (due to chronic blood loss), and anemia mainstay. This includes Pentasa in CD, Asacol in UC and
of chronic disease. CD involving the proximal small Rowasa for rectal involvement.
intestine (duodenum) may have difficulty absorbing '99er'- There has been re-activation of tuberculosis with
oral iron and occasionally parenteral iron replacement infliximab, and therefore PPD test for latent TB should be
is necessary. done prior to treatment. If positive, patients should receive
Hypercoagulability: Strokes, retinal thrombi, and isoniazid.
pulmonary emboli are not uncommon in patients with '99er'- Ischemic colitis- Patient suddenly presents with
IBD. abdominal pain that may be accompanied by stools with
blood clots. A classic presentation that develops later is
Diagnosis severe abdominal pain, which is out of proportion to
physical findings. Patient may have fever and on
Lab studies: ESR is typically elevated and has been
examination may present with localized tenderness.
used to monitor disease activity. Hypokalemia reflects
Abdominal distention, guarding and bowel sound absence
the severity of the diarrhea. CD can result in vitamin
are associated with intestinal infarction and hence are
B12, calcium, vitamin K, and iron deficiencies because
manifestation of disease progression. Patient is typically
of malabsorption and hence PT may be found to be
above 60 years of age and has predisposing factors for
prolonged.
development of CAD. Severe ischemic colitis requires
Serologic tests: pANCA have been identified in some
surgical resection of involved bowel.
patients with UC, and anti-Saccharomyces cerevisiae
antibodies (ASCA) have been found in patients with
Irritable Bowel Syndrome (IBS)
CD.
Imaging: IBD is diagnosed with endoscopy (skip It is a functional GI disorder characterized by abdominal
lesion in CD, friable mucosa in UC) and sometimes pain and altered bowel habits in the absence of any specific
with barium studies (cobblestoning in CD, lead pipe organic pathology.
colon in UC).
Biopsy: Biopsy shows granuloma in CD, but not in Clinical Features and Diagnosis
UC. The Rome III criteria for the diagnosis of IBS require that
patients must have recurrent abdominal pain or discomfort
Treatment for at least 3 days per month during the previous 3 months
The medical approach for patients with IBD is symptomatic that is associated with 2 or more of the following:
care. The first step in medication therapy is usually Relieved by defecation
aminosalicylates. If the IBD fails to respond to Onset associated with a change in stool frequency
aminosalicylates, the second step is high dose Onset associated with a change in stool form or
corticosteroids (budesonide). They tend to provide rapid appearance
Gastroenterology 135
Four bowel patterns may be seen with IBS. These Majority of carcinoids (95%) are present in GIT and
patterns include diarrhea predominant, constipation constitute the most common primary tumor of small
predominant, mixed diarrhea and constipation, intestine and appendix. But the serotonin produced from
alternating diarrhea and constipation. Patient may also these GIT carcinoids is not able to show its effect because
complain of abdominal bloating and mucorrhea. it is soon metabolized during its passage through liver
(into 5-HIAA and excreted into urine). On the other hand
Treatment
bronchial carcinoids, though rare are very notorious for
IBS is a chronic illness and has no cure. High fiber diet, their clinical presentation as they are directly secrete into
exercise and adequate fluid intake are initial measures systemic circulation. Hence, presence of carcinoid
taken. In patients where diarrhea predominates, syndrome usually signifies metastatic tumor or rarely
antidiarrheal agents like loperamide or diphenoxylate bronchial carcinoid. It may be associated with scleroderma.
should be given. Bulking agent like psyllium, and
lactulose, or enemas are indicated. Tegaserod (5-HT4 Clinical Features
agonist) may also be used. TCAs are used even in absence
Bowel carcinoids due to their anatomical location may
of depression, especially when patient is suffering from
chronic pain. Antispasmodic agents (hyoscyamine, present with pain, intestinal obstruction, palpable mass,
dicyclomine etc) are also used to relax bowel wall. perforation, or GI bleed. Features of carcinoid syndrome
The most important component of treatment is to include:
establish an effective and therapeutic relationship with diarrhea and abdominal cramps
the patient and his or her family. tachycardia and hypotension
pellagra due to niacin deficiency (excessive
Diarrhea (Complete Topic in Infectious production of serotonin causes tryptophan deficiency,
Disease Chapter) which in turn causes niacin deficiency).
flushing of skin (along with diarrhea- diagnosis
Stool osmotic gap: 290-2(stool Na++ stool K+). Any value
clincher) and telangiectasia of the face, and neck
< 50 is considered to be normal. Normal anion gap is seen
in IBS, factitious disorder (both have normal body weight), skin desquamation
secretory diarrhea, and laxative abuse (body weight is right-sided endocardial fibroelastosis - leading to
increased). Elevated anion gap with increased stool fat right-sided heart failure as it causes tricuspid
content is seen in malabsorption, bacterial overgrowth, regurgitation and pulmonary valve stenosis
and pancreatic dysfunction; normal fat content is seen in Wheezing attacks (due to bronchospasm).
lactulose/sorbitol ingestion, laxative abuse, or lactose
intolerance. Diagnosis
Clinical history gives enough clue and diagnosis can be
Carcinoid Syndrome confirmed by measuring elevated 24 hour urinary 5-
It is a syndrome due to production and secretion of hydroxyindolacetic acid level (5-HIAA) or by
serotonin from neuroendocrine tumors (carcinoids). somatostatin receptor scintigraphy.
Secretory (by viruses, toxins, No change in diarrhea after fasting, Fecal fat content, toxin evaluation, stool anion gap
or increases fat content) normal. (normal)
Osmotic(lactose intolerance, Bloating and gas with malabsorption Stool anion gap (increased)
sorbitol/mannitol ingestion)
Exudative (mucosal inflam- Tenesmus, frequent diarrhea with often Elevated ESR and C-reactive proteins.
mation, IBD, colon Ca) small volume Colonoscopy
136 The Definitive Review of Medicine for USMLE
Treatment
Cancer localized to mucosa, submucosa, and muscularis
layers should be resected. Once cancer spreads beyond
these layers or metastasizes chemotherapy is indicated.
The preferred regimen is irinotecan plus 5-FU/leucovorin
(Saltz regimen).
'99er'- Family history of colon cancer- in such patients,
screening should begin at an age of 40, or 10 years earlier
than the family member who had colon cancer, whichever
is younger. Fig. 8.1: Polyposis and cancer syndromes
Gastroenterology 137
stool, or melena, unless if hemorrhage is high enough when that endoscopy cannot see the source. A nuclear bleeding
even upper GI bleed may present as blood in stool. scan (technetium tagged red cells) is used to detect low
Massive hemorrhage presents with a systolic blood volume bleeds. Capsule endoscopy is the newest modality
pressure of < 90 mm Hg and a hemoglobin level of 6 g/dL to visualize the small bowel in which a patient swallows
or less and is a life-threatening condition. Orthostatic a capsule with a camera that transmits images to a receiver
hypotension (systolic blood pressure fall of >20 mm Hg or outside. If a patient is unstable, arteriography or
>10 point rise in pulse on change of position) in a patient exploratory laparotomy may be done.
with GI bleed is usually indicative of blood loss of more
than 1000 mL or 20% of total volume. Vital signs reveal
tachycardia at 10% volume loss and shock at 30%volume MALABSORPTION SYNDROMES
loss. Malabsorption syndromes encompass a number of
When patient presents with GI bleeding, priority is different clinical entities that result in chronic diarrhea,
given to management of bleeding and symptomatic abdominal distention, and failure to thrive due to defects
treatment rather than finding the cause of bleeding, which in the digestion and absorption of food nutrients by the
should be sought only once the bleeding is managed. gastrointestinal tract. Most common malabsorption seen
The initial goal of therapy should be to correct shock clinically includes that of fats and carbohydrates, with
and coagulation abnormalities and to stabilize the patient lactose intolerance being the most common of all.
so that further evaluation and treatment can proceed.
Patient should immediately receive 2 large-bore IV line Lactose Intolerance
and blood sample should be sent for various tests, typing
Lactose intolerance is a common disorder and is due to
and cross matching. In cases of massive hemorrhage as
the inability to digest lactose into its constituents, glucose
described above, patient may require transfusion of at least
and galactose, secondary to low levels of lactase enzyme
5 units of blood. Fresh frozen plasma is given if PT is more
in the brush border of the duodenum and is perhaps the
than 1.5 times the normal. Platelet transfusion is also
single most common potential cause of diarrhea.
indicated if count comes out to be < 50,000/mm3. Majority
of GI bleeding stops spontaneously during fluid Clinical Features
resuscitation.
Else measures to decrease active bleeding may be Symptoms of lactose intolerance include loose stools or
undertaken, depending on cause of bleeding like: diarrhea associated with abdominal bloating and pain,
Variceal bleeding- decrease portal hypertension by flatulence, nausea, and borborygmi upon ingestion of
giving octreotide, or endoscopic banding if it fails and dairy products (diagnosis clincher). The diarrhea never
transjugular intrahepatic portosystemic shunting has blood or leukocytes in it.
(TIPS) if both fail. A Blakemore tube may be used to
tamponade the bleeder till the time TIPS is performed. Diagnosis
PUD- PPI (not H2 blockers), endoscopic epinephrine Routinely its diagnosed by simply removing milk, cheese,
injection, thermal contact, and laser therapy. and all other dairy products (except yogurt) from the diet
Diverticular bleeding- epinephrine injection, and observing patient for resolution of symptoms, which
embolization, catheter directed vasopressin, or rarely should occur within 24 to 36 hours.
surgery has took performed if it does not stop of its Stool analysis: A precise diagnosis can be established
own. by finding an increased stool osmolality and increased
'99er'-TIPS- most common complication is worsening osmolar gap. Acidic stool is defined by a pH level of <
of hepatic encephalopathy.
5.5. This is an indication of likely carbohydrate
Endoscopy is the most accurate test to determine the malabsorption, even in the absence of reducing
etiology of both upper and lower GI bleeding. First upper substances.
GI bleed should be ruled out. When both upper and lower Breath hydrogen test: This is the diagnostic test of
GI endoscopy are not able to find the source of bleeding, choice. Subjects are administered lactose after an
the source most probably lies in small bowel- the part of overnight fast (of at least 8 hours), after which expired
GIT that is not clearly accessible by both type of air samples are collected and a rise in breath hydrogen
endoscopies. Angiography is useful in extremely high- concentration > 20 ppm over the baseline after lactose
volume bleeding in which so much blood is coming out ingestion suggests lactase deficiency.
Gastroenterology 139
of ascites, in the setting of a positive ascites culture. Culture- Encephalopathy: Lactulose is helpful in patients with
negative neutrocytic ascites is observed more commonly. the acute onset of severe encephalopathy and in
The most commonly used regimen in the treatment of SBP patients with milder, chronic symptoms. This
is a 5-day course of cefotaxime. nonabsorbable disaccharide stimulates the passage
'99er'-Peritonitis- is often suggested by severe pain that of ammonia from tissues into the gut lumen and
is significantly relieved when patient lies quietly inhibits intestinal ammonia production. Neomycin
(diagnosis clincher). Other features include abdominal or metronidazole serves as second-line agents by
guarding, localized or diffuse tenderness, and in severe decreasing the colonic concentration of ammoniagenic
cases absent peristalsis. It is caused by either rupture of bacteria.
viscera, pancreatitis, trauma, pelvic inflammatory disease Coagulopathy: Although vitamin K may be given, it is
(PID), etc. With exception of PID and pancreatitis, not effective.
diagnosis and therapy of peritonitis involves emergency Anorexia: Zinc deficiency is commonly observed in
exploratory laparotomy. patients with cirrhosis and treatment with zinc sulfate
'99er'- Hepatorenal syndrome- is thought to be present at 220 mg orally twice daily may improve dysgeusia
when a cirrhotic patient presents with sign of renal failure and can stimulate appetite.
and there is no other possible cause of renal failure. Also Pruritis: Cholestyramine is the mainstay of therapy
the condition doesn't improve even after volume expansion for pruritis of liver disease.
or diuretic withdrawal. Its diagnosis is based on the '99er'-Total abstinence from alcohol- is a prerequisite
presence of a reduced GFR in the absence of other causes for success of any therapeutic measure undertaken for
of renal failure in patients with chronic liver disease. cirrhosis like TIPS. Liver transplant patients are required
Serum creatinine level is > 1.5 mg/dL with urine osmolarity to abstain from alcohol at least 6 months before procedure.
higher than plasma and urine sodium <10 mEq/L. Its best '99er'-HCV infection- is not a contraindication to liver
treatment is liver transplantation. transplantation or TIPS. Though HCV recurs in all HCV
'99er'- Child-Turcotte-Pugh score- used to select patient positive patients who receive liver transplant, the outcome
who require liver transplant. Transplant is indicated in of transplantation is not much affected.
patient with score >7. '99er'-Isolated varices- are seen in splenic artery
thrombosis in chronic pancreatitis.
Treatment
'99er'-Steatosis (fatty liver) - most common causes are
Once it develops, there is nothing that can cure a patient of alcohol, obesity, and DM. It is found incidentally when
cirrhosis, other than liver transplantation. Management biopsy is done for some other purpose, or a LFT may show
is symptomatic and is targeted towards controlling and 2-3 times rise in liver enzymes. The etiological factor can
taking care of the complications. be diagnosed only on basis of clinical history correlation.
Ascites: Some patients with mild ascites respond to
sodium restriction, or diuretics (usually spirano- Primary Biliary Cirrhosis
lactone) taken once or twice per week. Other patients
It is an autoimmune, chronic, and progressive cholestatic
require aggressive diuretic therapy. Even TIPS may be
disease of the liver that involves destruction of the small-
required if it's recurrent and severe. Patients with
to-medium bile ducts which leads to progressive
refractory ascites who are not candidates for TIPS or
cholestasis and often end-stage liver disease. It is
liver transplantation may reasonably be treated with
commonly seen in middle-aged women. It is associated
peritoneovenous shunts.
with other autoimmune diseases like RA, Sjogren's
Portal hypertension and varices: are managed with
syndrome, and scleroderma.
propranolol to prevent bleeding. TIPS is very effective
treatment to prevent variceal bleeding. In case of active
Clinical Features
recent variceal bleed, priority in management should
be given to airway protection and hemodynamic Fatigue is the first reported symptom and may be
stability. In case of recent re-bleeding, endoscopic associated with depression and obsessive-compulsive
therapy with scelerotherapy should be tried first and behavior. Pruritus is also very common. Findings on
if not successful, should be followed by band ligation. examination include hepatomegaly, splenomegaly,
If both fail, Blackmore-sengstaken tube should be used. jaundice, hyperpigmentation, osteoporotic fractures,
Gastroenterology 145
9 Endocrinology
CARBOHYDRATE METABOLISM DISORDER lack the ability to overcome this resistance, though
insulin level may be high, low or normal.
Diabetes Mellitus (DM) About 90 percent of patients who develop type 2
diabetes mellitus are obese.
It is a group of metabolic diseases characterized by high
Although type 2 diabetes mellitus typically affects
blood glucose levels, which result from defects in insulin
individuals older than 40 years, but now because of
secretion, or action, or both and results in various
the epidemic of obesity and inactivity in children,
complications. Insulin is produced by the beta cells of
type 2 diabetes mellitus is occurring at younger and
the islets of Langerhans located in the pancreas and is younger ages.
chief controller of blood glucose levels. No autoantibodies are associated with NIDDM
Because patients with type 2 diabetes mellitus retain
Classification the ability to secrete some endogenous insulin, those
who are taking insulin generally do not develop
Type I or IDDM (Insulin dependent DM):
ketosis if it is stopped. Therefore, they are considered
The absence, destruction, or loss of beta cells of
to require insulin but not to depend on insulin.
pancreas, usually due to autoantibodies, results in
It is proposed that NIDDM may be an autosomal
type 1 diabetes.
dominant transmitted disease.
Insulin deficiency usually develops after the
99er-Stress due to any illness can increase insulin
destruction of 90 percent of islet cells.
resistance which leads to poor glycemic control. In the
Typically patients have lean body structure with age
progression from normal glucose tolerance to abnormal
of onset being usually < 30 years and therefore it is
glucose tolerance, postprandial glucose levels first
also called juvenile onset diabetes.
increase. Eventually, fasting hyperglycemia develops as
Most children with diabetes have IDDM and a
inhibition of hepatic gluconeogenesis declines.
lifetime dependence on exogenous insulin.
99er-Risk of DM by drugs: Risk for developing new
Absence of insulin makes them prone to ketosis.
DM by ACE-I (also insulin resistance) and
Associated with HLA-DR3, DR4.
Metformin. Risk is by blockers and hydro-
Patients have detectable serum islet cell cytoplasmic
chlorthiazides.
antibodies or antibodies to serum glutamic acid
99er-Metformin contraindicated in alcoholics, CHF
decarboxylase and also to insulin.
and renal failure. When given along with alcohol, it
Pancreatic biopsies show dense lymphocytic
causes hypoglycemia, lactic acidosis.
infiltration.
99er-PCOS patients- are very much insulin resistant.
Honeymoon period: After initial symptoms of IDDM
Ovulation can be improved by decreasing insulin
(like ketoacidosis) there is a symptom-free interval (the
resistance by exercise, metformin or losing weight.
honeymoon period), during which no treatment is
Therefore, continue metformin in these patients till
required. This is most probably caused by stress-induced
pregnancy is confirmed. After that stop metformin and
epinephrine release, which blocks insulin secretion.
start insulin. Another drug that is used in PCOS but
99er-Autoimmune polyglandular syndrome: keep in
contraindicated in pregnancy is spironolactone (because
mind this syndrome when IDDM patient starts requiring
of its anti-androgenic action).
decreasing dose of insulin, which is because of
Maturity-onset diabetes of the young (MODY): is a
development of adrenal failure in these patients.
form of type 2 diabetes mellitus that affects many
Type II or NIDDM (Non-insulin dependent DM): generations in the same family with an onset in
It is a heterogeneous disorder and most patients with individuals younger than 25 years. Several types
NIDDM have insulin resistance, and their beta cells exist.
148 The Definitive Review of Medicine for USMLE
Gestational Diabetes Mellitus (GDM): is defined as Two hour postprandial glucose > 200 mg/dl after a
any degree of glucose intolerance with onset or first 75 mg oral glucose tolerance test on two separate
recognition during pregnancy. Untreated GDM can occasions.
lead to fetal macrosomia, hypoglycemia, hypocal-
Hb A1c: formed due to nonenzymatic glycosylation of
cemia, and hyperbilirubinemia. In addition, mothers
hemoglobin. It is very useful for observing compliance
with GDM have increased rates of cesarean delivery
of treatment and glucose control as a strong correlation
and chronic hypertension.
exists between average blood-glucose concentrations over
Latent autoimmune diabetes of the adult [LADA]:
an 8- to 10-week period and HbA1c. Check HbA1c levels
older patients with late onset of diabetes who
every 3 months. In diabetics, values less than 7 percent
nonetheless take insulin and seem to share
are associated with an increased risk of severe
characteristics of patients with type 1 diabetes.
hypoglycemia; values more than 9 percent carry an
Pre-diabetes: is defined by a fasting blood glucose
increased risk of long-term complications. Therefore,
level of 100-125 mg/dL or a 2-hour post oral glucose
most clinicians aim for HbA1c values of 7-9 percent.
tolerance test (OGTT) glucose level of 140-200 mg/
A fasting C-peptide level >1 ng/dL in a patient who
dL. Patients, who have pre-diabetes, have an
has had diabetes for more than 1-2 years is suggestive of
increased risk for macrovascular disease as well as
type 2 diabetes. Autoantibodies can be useful in
diabetes.
differentiating between type 1 diabetes and type II
Metabolic syndrome (syndrome X/insulin-resistance
diabetes. Anti-GAD65 antibodies are present in 80
syndrome): thought to be due to insulin resistance,
percent of adult patients with new-onset type 1 diabetes
can occur in patients with overtly normal glucose
(NADA).
tolerance, prediabetes, or diabetes. It is characterized
by central obesity and dyslipidemia. Hypertension
Management
is a common feature. Eventually, clinically apparent
insulin resistance develops. Patient typically has Objective in DM management should be to control
aconthosis nigricans in flexural areas. symptoms, prevent acute symptoms and limit long-term
complication.
Clinical Features
Type Time of onset of action Peak effect time
Initial presenting symptoms most often are due to
Aspart 10-15 minutes 0.5-1.5 hours
hyperglycemia. Polydipsia, polyuria and polyphagia
Lispro 10-15 minutes 1-2 hours
may be typically the first presenting symptoms.
Sometimes the presenting symptoms may be either an Regular 45 minutes 2-5 hours
acute or chronic complication including recurrent NPH 2-4 hours 6-10 hours
vulvovaginitis/balanitis, blurred vision and the ones Glargine 4 hours Lasts up to 16-20 hours
mentioned below. INSULIN FORMULATIONS
Blood Glucose Monitoring cells are destroyed and acarbose causes more severe
steatorrhea.
Pre-breakfast glucose level reflects pre dinner NPH
99er-Acarbose blocks carbohydrate break down in
dose.
the intestinal tract. The most significant side effect is GI
Pre-lunch glucose level reflects all pre-breakfast
disturbance due to increased undigested carbohydrate
regular insulin.
in the stool.
Pre-dinner glucose level reflects for all pre-breakfast
NPH dose Other Management Concerns
Bedtime glucose level reflects for all pre-dinner A low fat diet with reduced carbohydrate should be
regular insulin dose. maintained. CAD risk factors should also be
99er-Exercise and IDDM- If patients are planning to controlled.
participate in rigorous exercise for more than 30 minutes, A baseline ECG to be obtained in all heart disease or
these patients may develop hypoglycemia. To prevent inpatients with age > 35 years.
hypoglycemia, they either can decrease the insulin by Diabetic nephropathy should be monitored annually
10-20 percent or can have an extra snack. These patients by a urinary analysis for microalbuminuria.
must maintain their hydration status during exercise. In Any diabetic planning a pregnancy should undergo
IDDM dont exercise when blood glucose > 250 mg/dl an eye examination
because ketoacidosis may develop. Intense exercise like Annual eye exams in all diabetics to check for signs
weight lifting should be avoided as it may lead to or of retinopathy or cataracts
enhance retinopathy. Keep up the vaccination against pneumococcal
99er-Insulin pumps- give the freedom to participate infection and also give the annual flu shot.
in exercise also. Annually check feet for neuropathy or ulcer.
NIDDM is treated first with weight reduction, a Somogyi effect: is rebound hyperglycemia in the
diabetic diet, and exercise. When these measures fail to morning because of counter regulatory hormone release
control the elevated blood sugars (after 3 months of after an episode of hypoglycemia in the middle of the
following the regimen), oral hypoglycemics are started. night.
Sulfonylureas are used in non-obese patients and Dawn phenomenon: is an early morning rise in
metformin is drug of choice in obese (TGs, HDL, plasma glucose requiring increased amounts of insulin
improves non-alcoholic steatotic hepatitis). Typical to maintain euglycemia.
stepwise management includes metformin, a glitazone
and a sulfonylurea. Oral hypoglycemic are also very Acute Complication
useful in treatment of MODY. If oral medications are still Diabetic ketoacidosis (DKA): It may be the presenting
insufficient, treatment with insulin is considered. Blood symptom of IDDM and is caused by severe insulin
glucose level is to be checked once at least. deficiency. It is precipitated by infection, stress, excess
99er Rosiglitazone can also be used in obese, if alcohol ingestion or insufficient/interrupted insulin
metformin is not tolerated. Insulin, sulfonyureas and therapy.
thiazolidinone all cause obesity. DKA is typically characterized by hyperglycemia over
99er-DM patient with renal failure: Insulin is 300 mg/dL, low bicarbonate level (<15 mEq/L), and
mainstay of therapy. Drugs that are not to be given in acidosis (pH <7.30 with increased anion gap) with
renal failure are metformin (causes metabolic acidosis) ketonemia and ketonuria.
and glyburide (extensively metabolized in kidney). Drugs
apart from insulin that can be used in treatment are Clinical Features
rosiglitazone, repeglinide, acarbose. It may present with nausea/vomiting, abdominal
99er-Thioglitazones are to be given carefully in CHF pain, rapid breathing (Kussmaul respiration), fruity/
patient as they cause salt and water retention. They are acetone breath, decreased perspiration (signs of
contraindicated in type III and IV VHF. dehydration), fatigue, anorexia or increased appetite,
99er-Chronic pancreatitis diabetics: Measure C confusion, coma.
peptide to differentiate between hyperglycemia of
NIDDM and chronic pancreatitis. These patients have Diagnosis
more risk of hypoglycemia as compared to NIDDM Based on typical signs and symptoms in a previously
patients. Glyburide is not effective in these patients as known IDDM patient or presence of:
150 The Definitive Review of Medicine for USMLE
drop, or paralysis of the third, fourth, or sixth Diabetic Foot (especially important for step 3)
cranial nerve.
Diabetic foot ulcers (DFU) precede 85 percent of
Autonomic neuropathy: presents with orthostatic
nontraumatic lower extremity amputations. The primary
hypotension and syncope as main
manifestations. Patients will also present with risk factor for the development of DFUs is loss of
delayed gastric emptying (gastroparesis), protective sensation due to neuropathy. Abnormal WBC
constipation, or diarrhea. If neuropathy also function and the presence of peripheral vascular disease
involves bladder leading to its dysfunction or allow wounds to become contaminated and infected by
paralysis, it will lead to urinary retention. organisms that normally are nonpathogenic. This
Impotence and retrograde ejaculation are explains the identification of unusual bacteria from the
common in men due to autonomic neuropathy. wounds of patients with diabetes. Motor peripheral
Its signs and symptoms are usually devastating neuropathy or Charcot arthropathy can produce bony
for the patient. deformity, which combined with the loss of protective
sensation, can result in skin ulceration from pressure or
Diagnosis from shear forces.
Diagnostic study of choice is nerve conduction study.
Depth Definition Treatment
Management classification
Strict glycemic control decreases development of new DM
neuropathy by 60-70 percent. 0 At-risk foot, Patient education,
no ulceration accommodative
Peripheral neuropathy requires drugs like gaba-
footwear, regular
pentin, amitriptyline, and carbamazepine for relieving clinical examination
the neuropathic pain. Erythromycin or metoclopramide 1 Superficial Offloading with total
can be used for treatment of gastroparesis and bethanecol ulceration, contact cast (TCC),
for urinary retention. Other symptomatic treatment not infected walking brace, or
should also be provided as required. special footwear
99er-Sildenafil (Viagra) - effective treatment of 2 Deep ulceration Surgical debridement,
impotence of varied reasons, is a selective inhibitor of exposing tendons wound care, offloading,
or joints culture-specific
cGMP-specific phosphodiesterase type V. Onset of action
antibiotics
is 60-90 minutes. Patient with renal disease and elderly 3 Extensive ulceration Debridement or partial
should be given smaller initial doses. It should be avoided or abscess amputation, offloading,
by patients taking nitrates for at least 24 hours before or culture-specific
after taking them. Side effects are headache, facial antibiotics
flushing, nasal congestion, dyspnea and transient altered
color vision (blue halo effect). Depth Classification of Diabetic Foot Lesions*
99er-Sildenafil and doxazosin- administration
should at least have a gap of 4 hours. Also there should Ischemic Definition Treatment
be a wait for at least 6 hours between taking a sildenafil classification
pill and flying a plane.
99er-Gastroparesis: is most commonly present in A Not ischemic
B Ischemic without Noninvasive vascular
association with diabetes. Electrolyte imbalance may also
gangrene testing, vascular
sometimes be the cause. It leads to delayed emptying of consultation if
food from the stomach into the small intestine and hence symptomatic
presents with early satiety, postprandial nausea, and a C Partial foot gangrene Vascular consultation
general sense of increased abdominal fullness and D Complete foot Major extremity
bloating. The diagnosis is generally obvious from gangrene amputation, vascular
presentation in a long-term diabetic after endoscopy consultation
excludes other diseases. Erythromycin (increases motilin) Ischemic classification of diabetic foot lesion
or metoclopramide may be used for treatment, though * Adapted from Brodsky JW: The diabetic foot. In: Coughlin
Cisapride is the only drug that is beneficial in long-term MJ, Mann RA, (Eds). Surgery of the Foot and Ankle. St Louis,
gastropathy of DM. Mo: Mosby; 1999: 911.
152 The Definitive Review of Medicine for USMLE
of luteinizing hormone releasing hormone (LHRH), 99er-Lactation suppression: Tight fitting bra and ice
which leads to decrease in luteinizing hormone (LH) and packs is treatment of choice. Bromocriptine is no longer
follicle stimulating hormone (FSH). used for this purpose.
Physiologic hyperprolactinemia is seen in stress, sleep, 99er-Pergolide, a drug previously used for the
nipple stimulation and in early nursing. Some treatment of hyperprolactinemia has been withdrawn
pathological states like primary hypothyroidism may also from the US market, because of heart valve damage
cause hyperprolactinemia. resulting in cardiac valve regurgitation.
Pathological hyperprolactinemia is seen in pituitary
adenomas (prolactinoma), dopamine synthesis blockers Acromegaly
like phenothiazines, metoclopramide etc. and dopamine
It is an uncommon hormonal disorder that develops
depleting agents like reserpine, methyldopa etc.
when pituitary gland produces too much growth
99er-Prolactinomas are the most common
hormone (GH) during adulthood that leads to an
functioning pituitary adenomas. They may be
insidious, chronic debilitating condition characterized by
microadenoma (usually women) or macroadenoma
soft tissue and bone growth. Mostly it is caused by
(usually men). These adenomas of pituitary may present
excessive GH secretion from a pituitary adenoma and
with visual field defect (diagnosis clincher).
rarely from ectopic neoplastic sites like lung cancer.
Excess secretion of GH in children leads to gigantism.
Clinical Features
Women typically present with a history of Clinical Features
oligomenorrhea, amenorrhea, or infertility, which
Patient in questions will typically present with swelling
generally results from prolactin suppression of
of the hands and feet, with patients noticing a change in
gonadotropin-releasing hormone (GnRH). Galactorrhea
ring or shoe size, particularly shoe width, so that they do
(plus infertility- diagnosis clincher) is due to the direct
not fit anymore (diagnosis clincher). Other skeletal and soft
physiologic effect of prolactin on breast epithelial cells.
tissue changes are coarsening of facial features, thickening
Men typically present with complaints of sexual
of skin folds, nose enlargement, prognathism (diagnosis
dysfunction, visual problems, or headache. Rarely it may
clincher) and separation of teeth, sometimes causing
also cause gynecomastia or galactorrhea in men.
underbite. Patient also has excessive sweating, body odor
In both sexes, the presence of a pituitary tumor may
and small outgrowths of skin tissue (skin tags). All the
cause visual-field defects or headache.
internal organs are also enlarged. Interstitial edema,
osteoarthritis, and entrapment neuropathy (carpal tunnel
Diagnosis
syndrome) are seen. Headaches and visual field defects
The first thing to do is to rule out the causes like drugs or are the most common symptoms due to local mass effect
hypothyroidism. Serum TSH should be used to rule out of the tumor and the most common manifestation is a
hypothyroidism. Prolactin level > 100 ng/ml suggest bitemporal hemianopsia due to pressure on the optic
probable pituitary adenoma. MRI is the imaging study chiasm. Impaired glucose tolerance, diabetes,
of choice for finding pituitary tumor. Pregnancy should cardiomegaly, hyperhidrosis, arthritis, and hypertension
always be ruled out first. are also seen.
99er-Leading cause of mortality in acromegaly is
Treatment cardiovascular disease, followed by DM and respiratory
problems.
When symptoms are present, medical therapy is the
treatment of choice. The dopamine agonist,
Diagnosis
bromocriptine mesylate, is often the initial drug of
choice. Vision improves even before sign of decrease in Screening test involves the measurement of GH after 100 g
tumor size is seen on MRI. of glucose is given orally. Normally a glucose load should
Surgical treatment: When tumor is associated with suppress levels of GH. This test is positive if GH remains
significant compressive neurological effect, medical high (>2 ng/mL in men or >5 ng/mL in women) and
therapy is not effective or is contraindicated. Also patients suggests acromegaly. Measurement of insulin-like
with macroadenoma who are not responsive to growth factor (IGF) or somatomedin (SMF) correlates
metoclopramide can be treated by surgery or radiotherapy. with disease activity. Once a firm biochemical diagnosis
154 The Definitive Review of Medicine for USMLE
of acromegaly is made, imaging studies like CT and MRI ejaculate, muscle weakness, and fatigue. Long-
are indicated, out of which MRI is preferred modality. standing hypogonadism leads to decreased hair
growth, soft testes, and gynecomastia.
Management In WomenPremenopausal women present with
A multimodality approach usually requires surgery as altered menstrual function, hot flashes, decreased
the first line of treatment, followed by medical therapy libido, breast atrophy, vaginal dryness, and
for residual disease. Radiation treatment is generally dyspareunia. Postmenopausal women usually
reserved for refractory cases. Some patients may respond present with headache or visual abnormalities.
to a dopamine agonist, bromocriptine. Octreotide is a Pubic and axillary hair growth is usually normal
somatostatin analog that reduces GH values in two thirds unless a concomitant ACTH deficiency exists.
of patients and causes partial tumor regression in 20-50 GH deficiency: In children results in growth failure
percent of patients. Pegvisomant, a GH receptor and short stature but is not clinically detectable in adults,
antagonist normalizes IGF-I levels in 90-100 percent of although may manifest as fine wrinkles and increased
patients, but may cause increase in GH levels and rarely sensitivity to insulin (hypoglycemia).
increase in tumor size also. Transphenoidal surgery Adrenocorticotropin (ACTH) deficiency: Acute loss
provides a rapid response, whereas radiotherapy results of adrenal function is a medical emergency and may lead
in slow resolution of disease. Some patients may develop to hypotension and death if not treated. Symptoms are
hypopituitarism in both of these modalities. nearly identical to those of primary adrenal insufficiency
but can be differentiated by lack of hyperpigmentation,
Hypopituitarism hyperkalemia.
Any lesion that destroys the pituitary or hypothalamus
or that interferes with the delivery of releasing factors to Diagnosis
the anterior pituitary may cause hypopituitarism. It may A variety of laboratory tests can be used, but significant
be caused by tumors of pituitary and hypothalamus, controversy exists regarding which tests are ideal.
granulomatous diseases, Sheehan syndrome, Individual tests to test the deficiency of individual
hemochromatosis, amyloidosis etc. Its diagnosis may be hormones are given along with the relevant topic.
easily missed as the symptoms and signs are frequently
protean and nonspecific, including alterations in Management
electrolyte levels, mental status, glucose levels, body
temperature, and heart rate. First hormone to present Management of hypopituitarism involves treating the
with deficiency is gonadotropin followed by GH, underlying causes. Multiple hormones must be replaced,
thyrotrpins, and adrenocorticotropin is the last one to but the most important is cortisol replacement.
become deficient.
99er-Pituitary apoplexy: is an emergency due to DISEASES OF THE POSTERIOR
hemorrhagic infarction of a preexisting pituitary PITUITARY LOBE
adenoma, and manifests as severe headache, nausea or
vomiting, and altered consciousness. Diabetes Insipidus (DI)
99er-Lymphocytic hypophysitis: is an autoimmune Diminished ability of patient to concentrate urine leading
disease that may present with hypopituitarism and is to polyuria and polydipsia associated with hyper-
usually associated with other autoimmune diseases like natremia. DI frequently starts in childhood or early adult
Hashimoto thyroiditis, gastric atrophy. life. It usually follows trauma or surgery to the region of
the pituitary and hypothalamus. DI either due to
Clinical Features insufficiency of ADH (vasopressin) or renal unrespon-
Hypopituitarism is usually a combination of several siveness.
hormonal deficiencies and rarely involves all pituitary Central DI: is caused due to decreased secretion of
hormones. ADH from posterior pituitary. It can be caused by
Gonadotropin deficiency (LH and FSH): neoplastic or infiltrative lesions in the hypothalamus
In menSymptoms include decreased libido, or pituitary, head trauma, surgery, meningitis,
varying degrees of erectile dysfunction, decreased radiotherapy, etc.
Endocrinology 155
Nephrogenic DI: is caused by renal resistance to the orally, or intranasally is an effective regimen. Drugs like
action of vasopressin. It is either idiopathic or chlorpropamide, clofibrate (no longer in US), or
secondary to sickle cell disease, pyelonephritis, carbamazepine can stimulate release of ADH and may
sarcoidosis, or drugs like lithium and demeclocycline. also be used.
It is commonly illicited with hypercalcemia, For nephrogenic DI, thiazides, amiloride, or
hypokalemia. chlorthalidone may be used, which enhance the
reabsorption of fluid from the proximal tubule.
Clinical Features
Syndrome of Inappropriate Secretion of ADH
Clinical findings of DI include polyuria (up to 3-20 L/
(SIADH)
day), polydipsia, severe dehydration, weakness, fever,
altered mental status, prostration, and death. Inappropriate secretion of the ADH due to any cause
interferes with renal excretion of water and results in
Diagnosis production of concentrated urine and hyponatremia.
Increased ADH causes water retention and extracellular
Various lab tests will show
fluid volume expansion without edema or hypertension,
hypernatremia
owing to natriuresis. The water retention and sodium loss
high serum osmolarity (usually > 287 mOsm/kg)
both cause hyponatremia, which is a key feature in
urine specific gravity < 1.005 and a urine osmolality
SIADH. It is caused by a varied array of factors like:
<200 mOsm/kg (hallmark of DI) (Diagnosis clincher)
The two types can be differentiated by looking for Central nervous system disease Trauma, tumor,
the response after injection of ADH. If the response is infections, cerebrovascular accident, subarachnoid
of normalization after injecting vasopressin, the diagnosis hemorrhage, GBS, multiple sclerosis.
of central DI can be made. Ruling out secondary causes, Carcinoma Lung (small cell carcinoma), pancreas,
such as diabetes mellitus, is also important. thymoma, ovary, lymphoma
The water deprivation test (Miller-Moses test), a semi Pulmonary disease - Tumor, pneumonia, COPD, lung
quantitative test to ensure adequate dehydration and abscess, tuberculosis, cystis fibrosis
maximal stimulation of ADH for diagnosis, is performed Drugs - Exogenous vasopressin, NSAIDs, diuretics,
typically with more chronic forms of diabetes insipidus. chlorpropamide, carbamazepine, tricyclic
99er-DI and pregnancy- DI may manifest during antidepressants, SSRIs, vincristine, thioridazine,
third trimester of pregnancy or during puerperium cyclophosphamide, clofibrate
because of a circulating enzyme named vasopressinase Surgery - Postoperative
that degrades circulating vasopressin, but has no effect Idiopathic (most common)
on desmopressin. The condition resolves spontaneously.
Primary Polydipsia/ Psychogenic Polydipsia: It is Clinical Features
characterized by primary increase of water intake and in
The key to the pathophysiology, signs, symptoms, and
contrast with DI and DM, its the polyuria which is the
eventual treatment of SIADH is an understanding that
driving force of increased water intake. This is seen most
the hyponatremia is a result of excess water and not a
commonly in anxious young women. Also patients
sodium deficiency. Signs and symptoms of
taking phenothiazines have this problem because of the
hyponatremia are primarily related to the dysfunction
dry mouth caused by anticholinergic effect of the drug.
of the central nervous system. There are no signs of
Primary polydipsia is also known to be caused by
edema or dehydration. Whereas most patients with
hypothalamic lesions affecting the thirst center.
serum sodium concentration above 125 mEq/L are
asymptomatic, those with lower levels typically have
Management
symptoms, especially in the setting of a rapid decrease.
In case of inadequate thirst, desmopressin is the drug of Anorexia, nausea, and malaise are the earliest findings,
choice. For central DI, hormone replacement with followed by headache, irritability, confusion, muscle
vasopressin subcutaneously or desmopressin (synthetic cramps, weakness, obtundation, seizures, and coma.
analogue of vasopressin with potent anti-diuretic When sodium concentration drops < 105 mEq/L, life-
properties but no vasopressive effect) subcutaneously, threatening complications are likely to occur.
156 The Definitive Review of Medicine for USMLE
Nonsuppressed cortisol response: Ectopic ACTH CT of abdomen since it is usually due to adrenal
producing tumor (carcinoid or small cell cancer). adenoma.
Perform an octeroide scan or chest and abdominal Secondary: The stimulus for adrenal production is
MRI/CT. If negative do pituitary MRI. usually decrease in intravascular volume and hence
The overnight 1 mg dexamethasone suppression test is extra adrenal. It may be associated with
requires administration of 1 mg of dexamethasone at renovascular hypertension like due to renal artery
11 pm with subsequent measurement of cortisol level at stenosis.
8 am. In healthy individuals, the serum cortisol level 99er-Most common cause of combination of
should be < 5 mg/dL. In most non-pituitary Cushing hypertension with hypokalemia is primary
syndrome, there would be no suppression and the level hyperaldosteronism.
would be at least 9 mg/dL. Patient with intermediate 99er-In boards, suspect primary hyperaldosteronism
levels need to further undergo low dose dexamethasone in any young patient who presents with muscle
test given for 2 days, which will inhibit ACTH secretion weakness, numbness and hypertension.
in normal subjects but not in pituitary tumor.
Brain MRI is indicated if patient with hypercortisolism Treatment
has no history of taking steroids, but presents with
Surgical adrenalectomy is done to correct hypertension
headache or visual disturbance. Cushing disease may be
and hypokalemia. Idiopathic hyperaldosteronism is
diagnosed in such a scenario.
usually treated medically.
99er-Inferior petrosal sinus sampling can also be
used to differentiate between ACTH source from pituitary
Adrenal Androgen Excess Disorders
or an ectopic site.
The adrenal androgens (AAs) secreted by zona reticularis,
Treatment are steroid hormones with weak androgenic activity.
Although AAs do not appear to play a major role in the
It is directed by the primary cause of the syndrome. The
fully androgenized adult man, they seem to play a role
treatment of choice for endogenous Cushing syndrome
in the adult woman and in both sexes before puberty.
is surgical resection of the causative tumor. The primary
Girls, women, and prepubertal boys may be negatively
therapy for Cushing disease is Transphenoidal surgery,
affected by AA hypersecretion in contrast to adult men.
and the primary therapy for adrenal tumors is
AAs are not as potent as testosterone, the major steroid
adrenalectomy. For medical treatment, of all the steroid
secreted by the testis, but a number of them, including
synthesis inhibitors available, Ketoconazole is probably
androstenedione, dehydroepiandrosterone (DHEA), and
the most popular and effective for long-term use and
its sulfate (DHEAS) may be converted to stronger
usually is the agent of choice.
androgens such as testosterone. AA excess disorders may
be caused by congenital adrenal hyperplasia, adrenal
Hyperaldosteronism
adenomas (rare), and adrenal carcinomas.
It is a syndrome associated with hypersecretion of the
aldosterone, characterized by hypokalemia, hyper- Clinical Features
tension and metabolic alkalosis. Hyperaldosteronism
All disorders of excess adrenal androgen production
may either be:
present with similar features and include precocious
Primary (Conn syndrome): Stimulus for production
puberty in males and hirsutism, oligomenorrhea, acne,
of hormone comes from within the adrenal gland.
and virilization in female. They may also present with
Increase in aldosterone is the initial step which leads
hypertension and electrolyte abnormalities.
to sodium retention and increase in intravascular
volume, but no edema. Renin levels should always
Congenital Adrenal Hyperplasia (CAH)
be measured to distinguish it from secondary
hyperaldosteronism, since rennin levels are always It encompasses a group of autosomal recessive disorders,
decreased in primary type. Other features that each of which involves a deficiency of an enzyme
distinguish it from secondary type are presence of involved in the synthesis of cortisol, aldosterone, or both.
hypernatremia and diastolic hypertension. Order a CAH should be considered in all infants exhibiting failure
158 The Definitive Review of Medicine for USMLE
different conditions and should be differentiated from Transient hyperthyroidism: results from subacute
each other. Hyperthyroidism refers to overactivity of the thyroiditis, a destructive release of preformed thyroid
thyroid gland leading to excessive synthesis of thyroid hormone in which hormone level may be extremely
hormones and accelerated metabolism in the peripheral elevated and is usually a painful thyroid condition and
tissues. Thyrotoxicosis, on the other hand, refers to the is also seen lymphocytic thyroiditis which is a painless
clinical effects of an unbound excessive thyroid hormone, condition seen most commonly in postpartum period.
whether or not the thyroid gland is the primary source. Extrathyroid source of hormones include
Graves disease/toxic diffuse goiter: is the most thyrotoxicosis factitia and ectopic thyroid tissue like
common cause of hyperthyroidism due to action of struma ovarii, or functioning follicular carcinoma.
thyroid stimulating autoantibody on TSH receptors on
thyroid gland. Its characteristic features are hyper- Clinical Features
thyroidism along with diffuse goiter, ophthalmopathy Typical features in boards are weight loss despite good
[exophthalmos, periorbital edema, chemosis (con- appetite, heat intolerance, palpitation, tremors, diarrhea,
junctival edema), injection, and proptosis] and sweating, menstrual irregularities (hypomenorrhea) and
dermopathy (diagnosis clincher) which is found more muscle weakness (diagnosis clincher). Patient may be
frequently in women in the fourth decade of life. emotionally labile and unable to sleep. A general
Dermopathy involves pretibial myxedemas, which are observation is that cardiovascular and myopathic
raised, thickened, well demarcated area usually occurring symptoms are more common in elderly which may
over the dorsum of the legs and feet that may be pruritic present with dyspnea, palpitation, atrial fibrillation
and hyperpigmented. Graves disease may be associated (diagnosis clincher), angina, or cardiac failure whereas
with other systemic autoimmune disorders such as nervous symptoms predominate in the younger patients.
pernicious anemia, myasthenia gravis, vitiligo, adrenal Patients have systolic hypertension, but diastolic
insufficiency, and type 1 diabetes mellitus. The whole pressure is usually normal. The ocular signs include
gland takes up iodine on RAIU. staring, infrequent blinking, and lid lag. The skin is warm
99er-Iodine induced thyrotoxicosis- may be seen and moist, and palmar erythema is present along with
after coronary angiography, especially in patient with fine and silky hair in hyperthyroidism.
pre-existing nodular goiter. RAIU is low in this case. This 99er Patients with hyperthyroidism are at increased
condition is either self-limited or use blockers for mild risk of rapid bone loss due to direct effect of thyroid
and antithyroid drug for severe cases. Potassium hormone on the bone cells that eventually leads to
perchlorate can be used in refractory cases. increased osteoclastic bone resorption.
Intrinsic thyroid autonomy is defined as increased
secretion of hormones without any external stimuli. It is Diagnosis
seen in: The diagnosis of hyperthyroidism is made on history and
Simple goiter: goiter is defined as enlargement of physical examination.
thyroid gland size and functionally it may lead to Laboratory studies include:
hyperthyroidism, hypothyroidism or euthyroidism. TSH- suppressed (primary) or high (secondary)
Toxic adenoma: a single hyperfunctioning follicular Serum T4 and T3-elevated.
thyroid adenoma. The excess secretion of thyroid RAIU(Radioactive iodine uptake)-
hormone occurs from a benign monoclonal tumor Diffuse toxic goiter: Increased
that usually is > 2.5 cm in diameter. Toxic multinodular goiter: Increased
Toxic multinodular goiter (TMNG)/Plummer Thyrotoxic phase of subacute thyroiditis: Decreased
disease: a nonautoimmune disease, more commonly Toxic adenoma: Increased
of elderly patients with long standing goiter. Thyroid Immunoglobulin assays: for thyroid stimulating
hormone excess develops very slowly over time and antibodies, anti-thyroid peroxidase (TPO) antibody.
even the signs and symptoms of hyperthyroidism are Differential diagnosis includes:
very mild. It is associated commonly with arrhythmia Anxiety
and congestive heart failure. Ophthalmopathy is Myasthenia gravis
never found in TMNG. RAIU uptake is high in Neurosis
nodules but decreased in rest of the gland. Parkinsonism
Endocrinology 163
Clinical Features are increased, T4 levels are normal to low, and T3 levels
are normal but T3 and T4 level fall as disease progresses.
Cretinism: Children with cretinism are usually born at
term or after term. Clinically they present with decreased Treatment
activity, large anterior fontanelle, poor feeding and
weight gain, persistent physiologic jaundice, hoarse cry, The treatment goals for hypothyroidism are the reversal
constipation, somnolence and hypotonia. of clinical progression and the corrections of metabolic
Juvenile hypothyroidism: Presents with delayed derangements, as evidenced by normal blood levels of
milestones and dwarfism, impaired mental development, TSH and free T4. Hypothyroidism can be adequately
retarded bone age, broad flat nose, widely set eyes, treated with a constant daily dose of levothyroxine (LT4).
protruding tongue, protuberant abdomen, umbilical If there is a strong suspicion of suprathyroid
hernia, coarse features, sparse hair, dry skin, and delayed hypothyroidism, give hydrocortisone first, then replace
dentition. thyroid hormone. Clinical benefits begin in 3-5 days and
In adults: Hypothyroidism commonly manifests as a level off after 4-6 weeks.
slowing in physical and mental activity but may be Treatment of myxedema coma involves high doses
asymptomatic. Classic signs and symptoms to be watched of IV levothyroxine and IV hydrocortisone. Mechanical
out for in question are cold intolerance, puffiness, ventilation and warming blankets may also be required.
decreased sweating, and coarse skin (diagnosis clincher). 99er-Calcium decreases levothyroxine preparation.
Other early presentations include constipation, stiffness Elderly hypothyroid patients require less levothyroxine.
and cramping of muscles, lethargy, carpal tunnel 99er-Sick euthyroid syndrome-may be caused after
syndrome, anemia of chronic disease, and menorrhagia. any illness. Patient will show slight features of
Later appetite decreases and weight increases, voice hypothyroidism. T3 and T4 level are slightly low and TSH
gets deeper and hoarse, intellectual and motor activity level is near normal. Treatment is needed only for the
slows, hair and skin become dry and even deafness may underlying illness.
occur.
On physical examination slow deep tendon reflexes NEOPLASIA OF THE THYROID
with prolonged relaxation phase are typically elicited. The thyroid is the most common endocrine organ to
As the disease progresses to stage of myxedema, it shows undergo malignant transformation. Thyroid adenomas
expressionless face, pale cool skin which is rough and are identified as being functioning/hyperfunctioning
doughy to touch, sparse hair, large tongue and periorbital (hot), nonfunctioning (cold), or photon deficient on tracer
edema. The myxedematous changes in the heart result imaging. Hot nodules (which are typically adenomas)
in decreased contractility, pericardial effusion, decreased are more often benign than the cold lesions. They are
pulse, cardiac enlargement, and decreased cardiac slow growing over many years. Management for
output. In the GI tract, achlorhydria and decreased hyperfunctioning adenomas includes ablation with
intestinal transit with gastric stasis can occur. surgery or radioactive iodine.
Myxedema coma is a very severe form of
hypothyroidism, which is frequently fatal and results in Thyroid Carcinomas
an altered mental status, hypothermia, bradycardia,
hypercarbia (due to respiratory depression), and Papillary Carcinoma
hyponatremia. Cardiomegaly, pericardial effusion,
It is the most common thyroid malignancy, representing
cardiogenic shock, and ascites may be present.
approximately 80 percent of all thyroid malignant
Myxedema coma most commonly occurs in individuals
diseases. Radiation exposure, especially during
with undiagnosed or untreated hypothyroidism and is
childhood, is associated with the development of
precipitated by external stress such as cold exposure,
papillary thyroid carcinoma. There is usually single
surgery, infection, hypnotics, or other medical
dominant nodule that is cold on thyroid scan. There is a
interventions.
bimodal frequency with peaks in the second and third
decades and then later in life. This tumor is slow growing
Diagnosis
and spreads via lymphatics after many years. An
Diagnosis of hypothyroidism is made by symptoms and increased incidence of papillary cancer is hypothesized
physical findings. In early hypothyroidism, TSH levels among patients with Hashimoto thyroiditis. It is also
Endocrinology 165
known to be associated with Gardner syndrome (familial calcitonin. It is encapsulated but without any typical
adenomatous polyposis). Histologically it presents with nuclear features and rarely involves lymph node, unlike
typical papillary structures within follicles that have papillary carcinoma.
epithelial cells that have nuclei with cleared centers Medullary carcinoma is component of MEN (multiple
(orphan annie eye). endocrine neoplasias). MEN type II is because of RET
Treatment: Is surgical excision whenever possible like. mutation.
With large tumors radiotherapy is used along with MEN type IIa (Sipple syndrome): Pheochromo-
surgery. TSH suppression therapy is also used. cytoma, medullary thyroid carcinoma, and (in one
half of cases) parathyroid hyperplasia.
Follicular Carcinoma MEN type IIb (mucosal neuroma syndrome):
Pheochromocytoma, medullary carcinoma, and
Follicular carcinoma accounts for 15 percent of all thyroid neuromas occur. Patients also have marfanoid
cancers. It represents an increased proportion of thyroid features.
cancers in regions where dietary intake of iodine is low 99er - blockade for 10-14 days is required in any
and is more common in the elderly and in women. This patient of MEN type II undergoing surgery because of
tumor is more malignant than papillary carcinoma. It associated pheochromocytoma.
spreads hematogenously with distant metastasis to lung The only effective therapy is thyroidectomy.
and bone.
Treatment: Near total thyroidectomy (NTT) is the Hrthle Cell Carcinoma/Oncocytic Carcinoma
preferred treatment. Postoperative radioiodine ablation
A variant of follicular carcinoma is a rare thyroid
is to be done. Small lesions can be treated with lobectomy
malignancy. About 75-100 percent of the tumor is
alone. It has the best prognosis overall.
composed of Hrthle cells (oxyphilic, oncocytic,
99er-Keep level of TSH between 0.1-0.3mU/liter in
Askanazy, or large cells) that contain abundant granular
papillary thyroid carcinoma because TSH stimulates the
acidophilic cytoplasm. It typically manifests in the fifth
tumor. During remission of tumor, keep it low by
decade of life.
increasing levothyroxine dose. For patient with metastatic
papillary carcinoma, complete TSH suppression is Treatment: Hrthle cell carcinomas behave aggressively.
required. These tumors most often do not take up radioactive
99er-Thyroglobulin is used as tumor marker after iodine. Patients with a diagnosis of Hrthle cell neoplasm
NTT. based on FNAB findings undergo lobectomy and
isthmectomy. If, the final pathologic result confirms
Anaplastic Carcinoma Hrthle cell carcinoma, patients return to surgery for
completion thyroidectomy. For tumors >5 cm or for
Anaplastic carcinoma is one of the least common thyroid palpable lymphatic metastases, total thyroidectomy is
carcinomas. It has the most aggressive biologic behavior often performed during the initial operation.
of all thyroid malignancies and one of the worst survival
Diagnosis: Thyroid carcinoma is suspected when there
rates of all malignancies in general. It often presents with
is recent growth of thyroid or an evident mass is seen
a painful enlargement.
with no tenderness or hoarseness. Patients with a history
Treatment: The progression of disease is rapid, and most of radiation therapy of the head, neck, or upper
patients die from local airway obstruction or mediastinum in childhood should also be suspected to
complications of pulmonary metastases within 1 year develop carcinoma but the latency period may be very
despite all treatment efforts. Total or subtotal long. The presence of a solitary nodule or the production
thyroidectomy is performed when the extent of of calcitonin is also clue to malignancy.
carcinoma permits it. Calcifications on X-rays such as psammoma bodies
suggest papillary carcinoma (characteristic-diagnosis
Medullary Carcinoma
clincher); increased density is seen in medullary carcinoma.
Medullary carcinoma accounts for 5 percent of all thyroid Thyroid nodule: Most common thyroid nodule is
cancers and occurs in sporadic or familial form. Tumors colloid, followed by follicular adenoma. The first step in
arise from the parafollicular C cells of the thyroid gland. diagnosis of a thyroid nodule is measurement of TSH,
C cells are neural-crest derivatives and produce with the subsequent steps (of T4, T3 measurement) all
166 The Definitive Review of Medicine for USMLE
dependent on TSH levels. If TSH is decreased, than the thought to be due to viral processes and usually follows
next step should be radionuclide scan. a prodromal viral illness. It is one of the most common
99er-If a thyroid nodule is > 1cm, go for FNAC (even causes of thyrotoxicosis that shows reduced uptake on
if TSH is normal). Otherwise do yearly ultrasound. RAIU. It may be associated with post- partum period.
Ultrasound is also recommended if nodule rapidly Clinical features: Presents with malaise, fever, pain over
increases in size. Ultrasound is better than CT for imaging the thyroid or referred to the lower jaw, ears, neck, or arms.
nodule. Radioactive scans not used here, as they are to The gland is enlarged, firm and tender (diagnosis clincher)
be used only in diagnosing toxic nodules in thyrotoxic
in this setting. Labs show ESR, RAIU, initial T3 and
patients.
T4 followed by their decrease, and features of
99er-Follicular Adenoma: histologically demons-
hypothyroidism.
trates invasion of the capsule and blood vessels. FNAB
shows large numbers of normal-appearing follicular cells. Treatment: Since it is self-limiting, only symptomatic
It is almost impossible to differentiate follicular adenoma treatment with low dose aspirin, along with control of
from follicular cancer. thyroid function is required. If aspirin does not relieve
the discomfort, prednisone can be used. Propranolol can
Thyroiditis be used to reduce signs and symptoms of hyperthyroi-
dism and low-dose levothyroxine may be used when
It is the inflammation of thyroid gland and includes: hypothyroidism develops.
Acute suppurative thyroiditis-due to bacterial
99er-Causes of thyrotoxicosis with RAIU: Subacute
infection
granulomatous (De Quervain) thyroiditis, thyrotoxicosis
Subacute thyroiditis: results from a viral infection of
factitia, iodine induced thyrotoxicosis.
the gland
99er-Thyrotoxicosis factitia- is characterized by
Chronic thyroiditis: autoimmune in nature.
exogenous administration of thyroid hormone.
Secondary thyroiditis: due to drugs like amiodarone
99er-No thyroglobulin detected in factitious
and interferon-alpha
thyrotoxicosis.
All have different clinical courses, and each can be
associated at one time or another with euthyroid,
Hashimoto Thyroiditis
thyrotoxic, or hypothyroid state.
It is a chronic inflammatory process of the thyroid with
Acute Suppurative Thyroiditis lymphocytic infiltration of the gland. Commonly found
antibodies are antithyroid peroxidase (anti-TPO) and
Most cases involve the left lobe of the thyroid and are
associated with a developmental abnormality or the antithyroglobulin (anti-Tg). It most frequently occurs in
persistence of a pyriform sinus from the pharynx to the middle- aged women, and is the most common cause of
thyroid capsule. Organisms responsible include S aureus, sporadic goiter in children. Histology shows lymphocytic
Streptococcus hemolyticus, and pneumococcus. infiltration of gland.
Clinical features: Presenting symptoms usually are fever, Clinical features: Patients most commonly present with
chills, neck pain, sore throat, hoarseness, and dysphagia. nonspecific symptoms suggestive of overt hypothyroi-
Neck pain is frequently unilateral and radiates to the dism. Diagnosis clincher will be a painless goiter on
mandible, ears, or occiput. Neck flexion reduces the physical examination. The goiter is rubbery and not
severity of the pain. The pain worsens with neck always symmetrical.
hyperextension. Diagnosis: History and physical examination are very
Treatment: is immediate parenteral antibiotic therapy helpful. High titers of antithyroid antibodies, namely
(penicillin or ampicillin) required before abscess antimicrosomal antibodies are present. Initially lab
formation begins. values are normal but as the disease progresses, TSH
increases and T4 and T3 decrease. Histologic confirmation
Subacute Thyroiditis is rarely needed.
It includes granulomatous, giant cell, or de Quervain Treatment: Treatment of choice is thyroid hormone
thyroiditis. This can occur at any age, although most replacement and the drug of choice is orally administered
commonly in the fourth and fifth decades. It is generally levothyroxine sodium, usually for life.
Endocrinology 167
99er-When lymphoma is suspected along with 25(OH)2D3) to increase serum calcium and decrease
Hashimoto thyroiditis then large bore needle biopsy is serum phosphate levels. Another hormone that
indicated. Suspicion for presence of lymphoma in a regulates calcium metabolism, though has minor role in
Hashimoto thyroiditis patient should arise from rapid humans, is calcitonin secreted by parafollicular cells of
increase in size of gland. thyroid.
synthesis of 1, 25 (OH)2 Vitamin D. PTH level is decreased with severe alterations of mental status. Surgery
and marked hypercalciuria may be seen. involving open surgical excision with frozen section
diagnosis is the only definitive treatment for severe
Primary Hyperparathyroidism hyperparathyroidism.
In mild and moderate hyperparathyroidism medical
Patients with a finding of hypercalcemia with normal
treatment is preferred if serum calcium is < 11.5 mg/dl
renal function and the absence of malignancy must be
or the patient is asymptomatic. The dietary calcium
suspected of having primary hyperparathyroidism.
should be reduced to 400 mg/d and oral intake of fluid
Primary hyperparathyroidism is usually the result of a
should be increased (2-3 L/day), which is also helpful in
single benign adenoma; a minority of patients will have
prevention of renal stone formation. Bisphosphonates
hyperplasia of all 4 parathyroid glands. Parathyroid
are the drug of choice, which mainly act by decreasing
carcinoma accounts for an insignificant minority. It may
bone resorption. Phosphor-soda should be given to
also be part of MEN type I and type II.
supplement body phosphates. Estrogen may be indicated
in hyperparathyroidism in postmenopausal women.
Clinical Features
Dialysis is last resort.
Most patients with primary hyperparathyroidism are 99er-Patient with MEN type I (Wermer syndrome-
asymptomatic or minimally symptomatic. Its sign and pancreatic islet cell tumor, parathyroid tumor, pituitary
symptoms may be remembered as presenting with adenoma) require removal of three and half to total
painful bones, renal stones, abdominal groans, and parathyroid glands.
psychic moans (Diagnosis clincher). All these features are
due to calcium resorption from bones and its increased Secondary Hyperparathyroidism
level in body. Cardiovascular findings include
It is characterized by pronounced parathyroid gland
hypertension and arrhythmias (short QT).
hyperplasia resulting from end-organ resistance to
parathyroid hormone (PTH). It results from chronic
Diagnosis
hypocalcemia and its most important cause is chronic
Elevated PTH levels in the setting of hypercalcemia renal failure. Chronic hypocalcemia and secondary
establish the diagnosis of hyperparathyroidism. hyperparathyroidism can also be products of
Measurement of ionized calcium is preferred over total pseudohypoparathyroidism, dietary vitamin D
calcium concentration, as a correction of adding 0.8 per deficiency, and intestinal malabsorption syndromes that
dL to the total serum calcium value for every 1 g/dL are characterized by inadequate vitamin D and calcium
decrease a serum albumin concentration of 4 g/dl is absorption.
needed to be used in case of hypoalbuminemia. Serum
phosphate is usually <2.5 mg/dl. Clinical Features
99er-Familial hypocalciuric hypercalcemia: is an
Patient has bone and joint pain, as well as limb
important differential of primary hyperparathyroidism.
deformities. Severe lower back pain occurs as a result of
They can be differentiated by the fact that urinary calcium
a collapsed vertebral body, and a spontaneous rib fracture
excretion is normal or elevated in primary hyper-
can cause sharp chest pain.
parathyroidism but in familial hypocalciuric hyper-
calcemia calcium excretion is decreased, to 200 and Diagnosis
creatinine is normal.
Patients with secondary hyperparathyroidism usually
have a low-normal calcium and elevated parathyroid
Treatment
hormone. The phosphate level may vary based on the
Severe hypercalcemia is an emergency and intravenous etiology, trending towards high values in renal
administration of isotonic saline is the first and most vital insufficiency and low values in vitamin D deficiency.
step in its management. Loop diuretics facilitate the Radiographs are the mainstays of the radiologic diagnosis
urinary excretion of calcium and can prevent the volume of secondary hyperparathyroidism because the
overload that may accompany the administration of large predominant changes are skeletal with abnormal
volumes of saline and is very useful in those presenting calcifications at various sites.
Endocrinology 169
10 Neurology
Wallenberg syndrome: Due to involvement of posterior Table 10.1: Localizing area of stroke
inferior cerebellar artery (PICA). Presents with
Symptom/sign Area involved
Ipsilateral facial sensory loss but contralateral
body sensory loss (diagnosis clincher) Broca (motor) aphasia Dominant frontal lobe
Ataxia Wernickes (sensory) aphasia Dominant temporal lobe
Vertigo
Dysarthria and dysphagia Decreased/no reflex + Lower motor neuron lesion
Horner syndrome fasciculation
Vertebral artery dissection: Presents with neck or head Hyperreflexia Upper motor neuron lesion
pain, Horners syndrome, dysarthria, dysphagia,
Apathy/uninhibition/inattention Frontal lobe
decreased pain and temperature sensation, dysmetria,
ataxia, and vertigo. Magnetic resonance angiography is a Memory impairment, Temporal lobe
sensitive test for diagnosing vertebral artery dissection as aggression, hypersexuality
a cause of stroke. Visual hallucination Occipital lobe
Lacunar stroke: are small non-cortical infarcts caused by
Inability to read, write, name Dominant parietal
occlusion of a branch of a cerebral artery. Risk factors are
or do math
hypertension, DM or polycythemia. Out of these
hypertension is most common and important risk factor. Ignoring one side/ difficulty Nondominant parietal lobe
They are of 4 types: dressing
1. Pure motor hemiparesis: Lacunar infarction in posterior Ataxia, nystagmus, intention Cerebellum
genu of internal capsule, presents with unilateral tremor (only on attempted
motor deficit (face, arm and some leg), mild dysarthria voluntary movement), dysarthria
(poorly articulated speech), no sensory or visual
dysfunction. Resting tremor, chorea Basal ganglia
2. Pure sensory stroke: In VPL nucleus of thalamus, Hemiballismus Subthalamic nuclei
presents with unilateral numbness, paresthesias,
hemisensory deficit involving face, arm and leg and CN III, IV Midbrain
trunk. CN V, VI, VII, VIII Pons
3. Ataxic hemiparesis: Lacunar infarction in posterior limb
CN IX, X, XI, XII Medulla
of internal capsule presents with weakness more
prominent in lower extremity, and ispilateral arm and
leg in co-ordination.
Diagnosis
4. Dysarthria-Clumsy hand syndrome: Lacunar stroke of
basis pontis, presents with hand weakness, mild motor Typical presentation will give you enough clues to
aphasia and no sensory abnormality. diagnose the defect in question. Useful investigations are:
Non-contrast CT: initial test of choice and is most
Thalamic stroke: Involves VPL part of thalamus that
sensitive to detect hemorrhage in brain. But for
transmits sensory info from contralateral part of body.
ischemia it takes up to 48 hours to show ischemic
Presents with hemianesthesia accompanied by
changes.
hemiparesis, athetosis. Dysesthesia (numbness and
Diffusion-weighted MRI: in detecting dying ischemic
tingling, burning feeling) of the area affected by the sensory
area.
loss is characteristic, and is called thalamic pain Perfusion weighted MRI: in detecting tissue at risk of
phenomenon. dying.
Edema that develops around an infarct becomes MR angiogram: in evaluating vessels
pronounced around 48 to 72 hours and this may lead to Transesophageal echo: in evaluating cardiac thrombi,
increased intracranial pressure, which may result in atrial septal defects or patent foramen ovale.
cerebral herniation if the infarction is large enough. Once ischemic stroke is diagnosed, search for possible
Corticosteroids can be given to treat this edema. embolic site can be done by echo or duplex.
174 The Definitive Review of Medicine for USMLE
Table 10.2
Dementia Delirium
Commonly caused by Alzheimer disease, vascular dementia Metabolic disorder, toxins, illness, withdrawal
Onset and course Insidious and chronic Acute and mostly short
Attention Mostly unaffected Poor
Memory impairment Remote memory spared (in early Global memory loss
dementia)
Arousal level Normal Fluctuates
Reversible No Usually yes
176 The Definitive Review of Medicine for USMLE
form new memories and confabulation. A very important appearance of infected brains, which become filled
concept, from MLE point of view, in treatment of alcoholics with holes until they resemble sponges under a
is to give IV thiamine before glucose to prevent microscope. It presents with myoclonus along
precipitation of Wernickes encephalopathy. Ocular with dementia. Late in the disease it may also
defects improve within hours of thiamine administration. present with blindness and weakness of extremity.
99er-Cerebellar vermis atrophy: seen in chronic Course of disease is shorter and more aggressive
alcoholism; is responsible for ataxic gait and tremors seen than Alzheimer disease (along with myoclonus
in them. diagnosis clincher).
99er-Elevation of the cerebrospinal fluid 14-3-3
DEMENTIA
protein in a patient with rapidly progressive dementia
Dementia is defined as a loss of mental ability severe enough and normal structural imaging is diagnostic of CJD. MRI
to interfere with normal activities of daily living, which is normal in them and electroencephalography shows
lasts more than six months and is not present since birth. periodic sharp waves.
There is no associated consciousness ateration or loss. Dementia with Lewy bodies (DLW): If dementia develops
within two years of diagnosis of Parkinsons disease,
Clinical Features than the dementia is known as Lewy body disease.
Else it is called Parkinsons disease dementia. The
All dementias have loss of memory along with other two conditions lie on the same disease spectrum and
associated features: can be considered subtypes of the more inclusive
1. Reversible dementias: These are dementias which are diagnosis of DLW. The three specific criteria for
due to reversible causes and have dementia as one of dementia with Lewy bodies are fluctuating
their features. The various factors that may present encephalopathy, parkinsonism, and visual
with dementia as one of its feature are: hallucinations (diagnosis clincher). A centrally acting
Hypothyroidism anticholinesterase agent may alleviate the inattention,
Vitamin B12 deficiency (many questions in exam hallucinations, and fluctuating encephalopathy of
will be dedicated to these 2 causes) dementia with Lewy bodies.
Encephalopathies Normal pressure hydrocephalus: Characterized by triad
Syphilis of incontinence, gait abnormality and dementia
Medication like anticholinergics (diagnosis clincher).
Trauma and hematomas Frontotemporal dementia: is usually associated with
Normal pressure hydrocephalus disproportionate atrophy of the anterior frontal and
Pellagra temporal lobes, a finding that is usually clearly
Brain tumor demonstrated on MRI. Picks disease is a sub-type of
2. Non-reversible dementia: frontotemporal dementia. It presents with personality
Alzheimers disease (AD): Most common cause of change (diagnosis clincher), lost initiative, and slowing
dementia. Early course of disease is marked by of thought, with relative preservation of recent
memory and visuospatial abilities defect. memory.
Hallucination and personality changes seen late
Dementia pugilistica: associated with history of
in the disease. Social etiquettes retained even in
boxing and cerebral atrophy will be evident on
presence of significant cognitive decline.
MRI.
Vascular dementia: Two types
i. Multi infarct: a characteristic step-wise AIDS dementia complex: AIDS patient presents with
progression (diagnosis clincher) usually progressive deterioration of cognitive function and
associated with CVAs. slowing of motor tasks.
ii. Binswanger disease: slowly progressive course,
involving subcortical white matter. Diagnosis
Creutzfeldt-Jakob disease (CJD): CJD belongs to a Initial work-up for finding the causes for dementia starts
family of human and animal diseases known as with ruling out the reversible causes. Initial tests should
the transmissible spongiform encephalopathies include TSH levels, vitamin B12 levels, CBC, RPR, HIV,
(TSEs). Spongiform refers to the characteristic electrolytes, LFT, glucose.
Neurology 177
Treatment Migraine
Proper emotional and medical support should be It manifests as recurring attacks, usually lasting 4-72 hours.
ensured to the patient and the family. Caregivers of a These attacks, which can interfere with normal functioning
demented patient are at increased risk for depression involve unilateral throbbing headache of moderate to
and anxiety. severe intensity, which may be aggravated by minor
Cholinesterase inhibitors like donepezil, rivastigmine, movements. They also usually involve nausea, sometimes
tacrine have modest efficacy on cognitive and global vomiting, and sensitivity to light, sound, and other sensory
function in mild to moderate Alzheimers disease. If no stimuli. It may be associated with typical triggers like
improvement is seen on drug treatment, it should be irregular sleep patterns, alcohol, chocolate, cheese, hunger,
discontinued after 3-6 months. Vitamin E and selegiline monosodium glutamate.
may delay the progression of Alzheimers disease but do Aura is a focal neurological deficit that precedes
not alleviate cognitive or psychiatric symptoms. migraine. Changes in regional cerebral blood flow can be
Memantine may be used in advanced Alzheimer disease. demonstrated in association with aura and neurologic
symptoms originating in the brain or brainstem are
reported which may be sensory, motor or visual. These
HEADACHE symptoms may range from the classical scintillating
Pain in head, neck or even jaw can be termed headache. scotoma (diagnosis clincher) to weakness and numbness in
Primary headache syndromes are: limbs. Migraine can be with aura, which is called classic
migraine and migraine without aura, called common
Migraine
migraine.
Cluster
Basilar migraines: Associated with dramatic
Tension
neurologic events such as total blindness, followed by
Various other diseases may also cause headache like vertigo, incoordination, difficulty speaking or
tumors, meningitis, temporal arteritis, glaucoma or CVAs. concentrating.
Complicated migraines: Neurological symptoms persist
Clinical Features even after the pain resolves.
Primary headaches present with a history of recurrent Migraine equivalents: Neurological symptoms in
episodes of pain. Following points in a patients history absence of headache or nausea and vomiting.
should ring bells of a underlying pathology in your ears:
first time episode of a severe headache Tension Type Headaches
Sinus tenderness (sinusitis) It generally produces a diffuse, usually mild to moderate
symptoms worsening recently pain over head bilaterally and sometimes also at back of
temporal artery tenderness (temporal arteritis) neck at the base of skull. Many people experience the
headache being described as worst headache of life feeling of having a tight band around their head (diagnosis
(intracranial hemorrhage) clincher). It doesnt disable the patient and he can go on
cranial bruit (AV malformation) with his regular activities of the day normally. It is the
Neck rigidity (Meningitis/Sub-arachanoid most common headache. It builds up slowly and may lasts
hemorrhage) for several days.
178 The Definitive Review of Medicine for USMLE
Lumbar puncture: Characteristic finding on LP is patients. Many patients with TM report a tight banding or
albuminocytologic dissociation i.e. elevated protein girdle-like sensation around the trunk and that area may
without any associated rise in cell count. be very sensitive to touch (Diagnosis clincher).
Electromyography and electroneurography (nerve
conduction study): they are highly accurate study in Diagnosis
diagnosing GBS.
Bed side vital capacity monitoring to keep an eye on First concern should be ruling out spinal cord compression
impending respiratory failure. by MRI or myelogram. Once that is ruled out, LP and CSF
examination and culture will help in reaching the correct
Treatment diagnosis.
Anterior Spinal Artery Infarct cord being the narrowest here. Acute cervical spinal cord
compression due to hyperextension injury is common in
This condition also involves loss of pain and temperature
elderly patients.
sensation due to involvement of anterior spinal artery that
supplies the tract carrying these sensations. Vibration and Clinical Features
touch sensations are spared. Another characteristic feature
is acute onset of flaccid paralysis that develops into a Constant, dull aching and sometimes radiating back pain
spastic paralysis over a course of few days to weeks is usually the first symptom in almost all patients. It may
(diagnosis clincher). increase with any activity that tends to increase intra-
thoracic pressure and feel like a band around abdomen.
Posterior Spinal Infarction This is followed, as given in the order, by motor weakness
in lower limbs (presenting as gait abnormality, ataxia and
It is rare and includes loss of vibratory sensation and even foot drop), sensory impairment (numbness, pins and
proprioception due to damage of the posterior column, needles, loss of sensation), loss of sphincter control and
suspended global anesthesia and segmental deep tendon impotence.
areflexia due to posterior horn involvement, and paresis Conus medullaris involvement presents as perineal
below the level of affected posterior portion of the lateral sensory loss and loss of anal wink. Cauda equina
column containing the crossed corticospinal tract. involvement presents as patchy sensory loss in lower
extremity (Saddle anesthesia) with bilateral weakness and
Diagnosis radicular pain.
MRI is the preferred modality. CT myelography can be
Diagnosis
used if MRI is not available.
History of fever, cancer or sphincter loss along with
Treatment dermatomal sensory level, upper motor neuron signs below
level of compression and increased lower extremity tone
Aspirin is standard drug therapy. on physical examination point towards the diagnosis of
cord compression.
SUBACUTE COMBINED DEGENERATION (BY Tests done are:
VITAMIN B12 DEFICIENCY) X-ray
MRI test of choice
Neurologic signs of vitamin B12 deficiency may manifest
CT myelogram- test of choice in situation where MRI
in the absence of hematologic signs of vitamin B12
is contraindicated
deficiency. It can cause dysfunction of the posterior
Somatosensory evoked potential (SSEP) testing or
columns and corticospinal tracts of the spinal cord,
magnetic stimulation may be used to see if nerve
causing paresthesias, loss of vibration and position sense,
signals can pass through the spinal cord.
sensory ataxia, weakness, and upper motor neuron signs.
Emergent MRI of the cervical spinal cord is indicated
These symptoms keep worsening with time. Other in any patient with quadriparesis after a fall.
symptoms that might be present include clumsiness,
change in mental state, depression, decrease in vision, Treatment
speech impairment and depression. Patient suffers spastic
paresis and ataxia, which are preceded by distal Always immobilize the neck if trauma is suspected.
paresthesias and weakness of extremities. Vitamin B12 Immediate high dose dexamethasone should be started
therapy is the treatment. to limit any damage by swelling. After the cause of
compression is known by various investigations, specific
SPINAL CORD COMPRESSION treatment towards that cause should be started. This
includes radiation therapy for radiosensitive tumors
It is a neurological emergency which can be caused by (lymphomas and myelomas), surgical decompression
bone, blood (hematomas), pus (epidural abscesses), tumors, through anterior approach for abscesses and herniated
TB (Potts disease) or a ruptured or herniated disk. Thoracic discs. Prognosis depends on functional status at the time
cord is most common site of compression due to spinal of presentation.
Neurology 181
99er-Cervical spondylosis is a chronic disorder of Tonic clonic/Grand mal epilepsy: The patient abruptly
degenerative and hypertrophic changes of the vertebrae, falls and may begin to have jerking movements of their
ligaments, and disks that may narrow the spinal canal body and head. Patient suffers loss of consciousness,
and cause cervical spinal cord compression. which may be preceded by a loud cry. Tongue bite and
99er-Lhermittes sign, an electric shocklike incontinence may typically occur (diagnosis clincher).
sensation down the neck, back, or extremities occurring Some patients also experience aura before onset of
with neck flexion is a helpful historical clue to a cervical seizure. Post-seizure, there is a post-ictal seizure
spinal cord disorder. confusion, somnolence or prolonged weakness.
Absence/Petit mal epilepsy: Only loss of consciousness
SEIZURE AND EPILEPSY without associated motor symptoms, except for eye or
muscle fluttering that sometimes occurs. Question
Seizures are the manifestation of abnormal
typically present a child in class who for 5-10 seconds
hypersynchronous discharges of cortical neurons. The stops the activity he was involved in, stares into space
clinical signs or symptoms of seizures depend on the and again resumes the activity with no memory of
location of these discharges in the cortex and it extent and event. They start before the age of 20 and there is no
pattern of their propagation in the brain. Epilepsy is a post-ictal state.
disorder characterized by the occurrence of at least Myoclonic: Characterized by a brief jerking movement.
2 unprovoked seizures 24 hours apart. These seizures may Most cases of myoclonic epilepsy occur during the
be caused by any pathology of brain, metabolic changes in first 5 years of life. They are of different types:
body and may even be functional/pseudo seizure. West syndrome: Characterized by triad of infantile
99er-Medication known to be associated with seizure spasm (child assumes jack-knife like, or folded
onset include imipramine, isoniazid, fluoroquinolones, position), psychomotor development retardation
meperidine, metronidazole etc. and hypsarrhythmia on EEG.
Lennox-Gastaut syndrome: characterized by minor
Clinical Features motor seizures which include myoclonic seizures,
atypical absence seizures (EEG finding not of
Partial Seizure
typical absence seizure), and atonic seizures
It begins in a focal or discreet area of the brain. It is further (sudden loss of postural tone).
subdivided into: Juvenile myoclonic epilepsy: A primary, genetic,
Simple partial: Twitching of the muscles or limbs, generalized epilepsy that typically manifests with
turning the head to the side, paralysis, visual changes, myoclonic jerks followed by a generalized tonic
or vertigo may occur. No change in consciousness clonic seizure.
occurs (diagnosis clincher). Patients may experience Status epilepticus: Prolonged, repetitive seizure activity
weakness, numbness, and unusual smells or tastes. that lasts > 30 minutes (these days even > 5 minutes
99er-An aura, experienced by many patients, is a considered as status epilepticus), during which the
simple partial seizure. patient is unconscious. It can be convulsive or non-
Complex partial seizures (temporal lobe): Conscious- convulsive type. Convulsive type is a neurological
ness is altered during this seizure. Patients may exhibit emergency.
automatisms (diagnosis clincher) such as sitting and Risk factors for recurrent seizures include multiple
standing, or smacking their lips together. Often previous seizures, a history of significant head trauma,
accompanying these symptoms are the presence of focal electroencephalogram abnormalities, and structural
unusual thoughts like uncontrollable laughing, fear, abnormality on MRI.
visual hallucinations, and experien-cing unusual 99er-Nonepileptic seizures of psychogenic origin: are
unpleasant odors. often associated with moaning, crying, and arrhythmic
Jacksonian epilepsy: The epileptic march when motor shaking of the body and can be differentiated from epilepsy
symptoms spread slowly from one part of the body to by their longer duration, normal electroencephalogram
findings, and maintenance of consciousness.
another.
99er-Cysticercosis- the most common cause of
seizures in South American immigrants, is due to infection
Generalized Seizure
with larval form of Taenia solium, the pork tapeworm. CT
Involvement of larger areas of the brain (often both will reveal calcified and/or ring enhancing lesion.
hemispheres) from the onset. It is further subdivided into: Treatment is with praziquantel.
182 The Definitive Review of Medicine for USMLE
Clinical Features Infections and trauma may acutely worsen the disease
and so does 2-3 months postpartum time, though MS
Its characteristic features are involuntary movements,
dementia, and behavioral changes. Onset is usually in attacks are fewer during pregnancy. Characteristically in
4th-5th decade. most patients with MS the symptoms may remain for
Involuntary movements: These may worsen and several weeks or may spontaneously resolve in few days
progress through mild chorea (involuntary, brief, and may remain so for months to year before a new attack.
irregular, unpredictable movements fleeting from one Patient may show Marcus Gunn pupil (afferent
body part to another are hallmarks of chorea) to pupillary defect) in which pupils may paradoxically dilate
dystonia and parkinsonism to akinetic-rigid to light stimulus due to delayed conduction
syndrome, with minimal or no chorea. Dysarthria and
Various clinical forms of the disease are
dysphagia are common.
Dementia: Initially presents with inattention and 1. Relapsing-remitting disease: Relapse of active disease
disinhibition. Later it progresses to slowing of with incomplete recovery during the remission periods.
cognition, impairment of intellectual function, and In at least 50% of patients with relapsingremitting
memory disturbances. multiple sclerosis, disease will evolve to a secondary
Behavioral changes: They have increased incidence of progressive course.
depression and suicide. May also develop psychosis, 2. Secondary progressive disease: Disease becomes
obsessive-compulsive symptoms, sexual and sleep progressively more aggressive with course of disease
disorders and changes in personality. and patient condition consistently keeps worsening.
3. Primary progressive disease (least common):
Diagnosis symptoms are progressive from the onset and
By genetic testing for presence of CAG trinucleotide repeats disability sets in early.
in HD gene on 4p chromosome. CT/MRI may show
atrophy of caudate nucleus. Diagnosis
MS can be suspected from clinical history when patient
Treatment (<55 years) complaints of multiple neurological complaints
Consider general safety measures and nonpharmacologic that are temporally widely separated and cant be
interventions first. The drug tetrabenazine has shown explained by single lesion (diagnosis clincher).
some positive effects in the treatment of chorea, for patients
with HD. SSRI are given for depression. Antipsychotic MRI
might also help.
This is the most accurate diagnostic test and also the most
99er-Juvenile HD (Westphal variant) - Age of onset is
younger than 20 years, and characterized by parkinsonian sensitive. This is the initial test of choice for MS. Active
features, dystonia, long-tract signs, dementia, epilepsy, and lesions are gadolinium enhanced and are known as
mild or even absent chorea. Dawsons fingers. In patients with possible multiple
sclerosis, new MRI white-matter lesions or new
MULTIPLE SCLEROSIS (MS) gadolinium-enhancing lesions on serial brain or spinal
cord MRI at least 3 months after an initial scan, indicate
It is an idiopathic inflammatory demyelinating disease of
dissemination of demyelination, even without a new
the CNS.
clinically evident attack.
Clinical Features
LP
The common initial presentations of MS are numbness or
CSF analysis upon LP shows characteristic, but
tingling and weakness of extremity, blurry and double
vision, urinary retention or urgency, unexplained central nonspecific, oligoclonal IgG in most patients. It may also
vertigo, positive babinski sign. Internuclear ophthalmo- show an increase of myelin basic protein during active
plegia (MLF syndrome) and scanning speech are also demyelination. Therefore, CSF analysis is recommended
classic features. Another typical feature of MS is heat only when clinical suspicion of MS is high but MRI is
sensitivity of symptoms which worsen after a hot shower. negative.
Neurology 185
Total protein level is slightly increases but any level swaying, tilting or falling down being felt. Presyncope is
beyond 100 mg/dl should go against the diagnosis of MS. generally described as light headedness along with
Mild pleocytosis (<50 cells/L) is also seen. palpitation, weakness and shortness of breath.
There are various clinical entities that can cause vertigo
Treatment and as described above they are broadly categorized into
those due to central or peripheral disease.
Relapsing-remitting disease: Drugs that are currently
Central: Vertigo caused due to lesion affecting
available and have proven efficacy in decreasing the brainstem vestibular nuclei or their connections. It is
number of active lesion on MRI are IFN- 1b (betas- not accompanied by hearing loss or tinnitus but other
eron), IFN-1a and glatiramer acetate (copaxone) signs of central lesion like dysarthria, diplopia, cortical
Secondary progressive disease: IFN-1b and blindness or numbness/weakness of extremity are
mitoxantarone are the drug option available for this present. Nystagmus present is vertical (specific for it)
entity. and does not suppress with fixation. Consider
Currently no drug is approved for treatment of primary multiple sclerosis in any patient who presents with
progressive disease. unexpected central vertigo.
If the above mentioned drugs are not tolerated in Peripheral: By lesions of labyrinth of inner ear or
patients than consider treating with cyclophosphamide, vestibular division of CN VIII. It is accompanied by
IV Ig therapy, methotrexate etc. Women taking immuno- hearing loss and tinnitus but other neurological
modulatory treatment for multiple sclerosis should use deficits usually absent. Vertigo tends to occur
effective contraception or if they want to become pregnant, intermittently and lasts for brief period. Nystagmus is
stop therapy several months before attempting to conceive. rotational and is suppressed with fixation. Horizontal
An acute exacerbation of MS is treated with 3 days of nystagmus is present in both types.
intensive IV steroid therapy followed by 4 weeks tapering Various entities with vertigo as a presenting feature are:
oral course. Plasmapheresis is done if patient is Side effects of medicine like aminoglycosides and
unresponsive to steroid therapy. furosemide.
Various drugs for symptomatic relief is as follows: Mnire disease: is due to over production of
Spasticity- baclofen. endolymph. Most commonly caused by head trauma
Pain (neuralgias or dysesthesisas) carbamazepine, and syphilis. It is episodic disease characterized by
triad of hearing loss, tinnitus and vertigo (with h/o
gabapentin, TCA.
trauma or syphilis- diagnosis clincher). A typical
Fatigue-fluoxetine/amantadine
episode lasts for 1-7 hours with waxing and waning
Erectile dysfunctionSildenafil
of symptoms.
Bladder hyperactivityoxybutinin
Schwannoma/Acoustic neuroma: A benign tumor that
Urinary retentionbethanecol
affects trigeminal and facial nerve and later
vestibulocochlear nerve. Presents with hearing loss
VERTIGO AND DIZZINESS (progressive sensorineural), tinnitus (repeated
Vertigo is a sensation of movement in absence of actual episodes lasting minutes to days), vertigo, facial pain
movement. Dizziness is a very nonspecific term that rarely and weakness, headache, ataxia.
conveys what really is going on. Vertigo can be caused by Benign paroxysmal positional vertigo (BPPV): Vertigo
central lesion (with acute onset) in brain like tumors, MS, is characteristically exacerbated by head movement
or change in its position (diagnosis clincher) with a
arteriovenous malformations of brainstem as well as
latent period of few seconds after the movement before
peripheral lesions (with gradual onset) like labrynthitis,
the vertigo begins and it lasts for few seconds to a
Mnires disease, positional vertigo, etc.
minute. Episodes of vertigo occur in cluster and persist
for several days. It is due to disturbance in otoliths
Clinical Features and Diagnosis
that sit on cupola of inner ear.
Clinically it is very important to distinguish vertigo (more Labrynthitis: disease usually follows a URTI and is
of neurological symptom) from presyncope (cardio- also accompanied by hearing loss and tinnitus.
vascular symptom). Vertigo is commonly described as Vertigo is severe and sudden in onset lasting for several
environment spinning around with sensations like days and is usually self limited.
186 The Definitive Review of Medicine for USMLE
AMYOTROPHIC LATERAL SCLEROSIS (ALS)/ Most common CNS tumors in adults are meningioma,
LOU GEHRIGS DISEASE gliomas, vestibular schwannoma, pituitary adenoma, and
primary CNS lymphomas.
It is a rapidly progressive, invariably fatal neurological
disease that attacks the neurons responsible for controlling Meningioma
voluntary muscles. In ALS both the upper motor neurons
and the lower motor neurons degenerate. It is a benign tumor of CNS, which is the most common
tumor of brain. These are usually small in size, and are
Clinical Features asymptomatic, hence found out incidentally. If
symptomatic, they present with progressive headache, or
It is characterized by pathologic hyperreflexia, spasticity,
focal neurological deficits according to location of tumor.
extensor plantar responses, along with atrophy,
They usually grow in size during pregnancy because most
fasciculations, and weakness. Muscle weakness in ALS
of them have receptors for progesterone.
usually begins distally and asymmetrically in the upper
or lower extremities or may be limited initially to the bulbar
Diagnosis
muscles resulting in dysarthria and dysphagia. Sensation
and cognition are completely intact. Patients have both CT typically shows a homogenously enhancing, partially
UMN and LMN lesions signs (diagnosis clincher). calcified extra-axial mass which is adherent to dura.
188 The Definitive Review of Medicine for USMLE
Table 10.4
Phenytoin* Gum hyperplasia, rash, hirsutism, lymphadenopathy, diplopia, dizziness, ataxia, Stevens-Johnson
syndrome (SJS). Toxic epidermal necrosis (TEN)
Phenobarbital Rash, ataxia, sedation
Valproic acid Hepatoyoxicity, thrombocytopenia, ataxia, tremor, GI irritation, hyponatremia. Long-term therapy
leads to urinary incontinence and frequency.
Lamotrigine SJS, rash, diplopia, ataxia
Ethosuximide GI disturbances, drowsiness, rash, hiccups
Carbamazepine Drowsiness, diplopia, headache, ataxia, leucopenia, dizziness, rash, urticaria, SJS, TEN, vertigo,
arrhythmias, SIADH, thrombocytopenia, hyponatremia, Stokes-Adams in patients with AV block.
Levodopa/Carbidopa Diskinesias (abnormal, involuntary movements), akathisias (restlessness), dystonias (treated by
botulism toxin).
Mitoxantrone Cardiotoxic
Primidone Acute intermittent porphyria (diagnosed by urine prophobilinogen)
Sumatriptan Contraindicated in CAD and pregnancy
Donepezil Mild peripheral cholinergic side effects like bradycardia and occasional AV blocks
Amantadine Dizziness, depression, postural hypotension, arrhythmias, nausea, insomnia
*Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the
serum phenytoin level is in the therapeutic range.
11 Dermatology
Table 11.1
Clinical Features
Erythema multiforme: Nonspecific prodromal
symptoms like fever and malaise along with burning
and itching at the future site of lesion may occur. It
presents with sudden onset of rapidly progressive,
symmetrical, and cutaneous and/or mucocutaneous
lesions, with concentric color changes in some or all
lesions (target/ iris lesions)[diagnosis clincher] that
has a centripetal spread. It typically occurs at back of
hands, palms and soles.
SJS/TEN: Typically, the disease process begins with a
nonspecific upper respiratory tract infection. It
Fig. 11.1: Erythema multiforme presents with generalized cutaneous and/or
(For color version see Plate 1) mucocutaneous lesions with blisters. Mucous
192 The Definitive Review of Medicine for USMLE
'99er'-Sweet syndrome (acute febrile neutrophilic Tinea unguium (onychomycosis): Infection of the nail
dermatosis): Tender erythematous papules and plaques and is characterized by onycholysis (nail plate
occur most often on the face, neck, upper trunk, and separation from nailbed) and thickened, discolored
extremities. Systemic findings are common and include (white, yellow, brown, black), broken, and dystrophic
fever (most often), arthritis, arthralgias, conjunctivitis, nails
episcleritis, and oral ulcers. Laboratory evaluation usually Tinea versicolor: It is a common, benign, superficial
reveals an elevated ESR, neutrophilia, and leukocytosis. cutaneous fungal infection usually characterized by
Biopsy reveals edema of the superficial dermis and a
hypopigmented or hyperpigmented macules and
dense infiltrate of neutrophils. Sweet syndrome often
patches on the chest and the back. The color of each
occurs in association with cancers, inflammatory
lesion varies from almost white to reddish brown or
disorders, pregnancy, and medication use.
fawn color. Patients often complain that the involved
INFECTIONS skin lesions fail to tan in the summer (diagnosis
clincher).
Fungal Infections
Dermatophytosis (tinea) is a fungal infection caused by Diagnosis
dermatophytes, a group of fungi that invade the dead It is mainly based on visual appearance, which is
keratin of skin, hair, and nails. Epidermophyton, confirmed by potassium hydroxide (KOH) test of the skin.
Microsporum, and Trichophyton are the common human
KOH dissolves the epithelial cells and collagen of the nail,
meeting genera.
but does not affect the fungus. Hence, a KOH preparation
Clinical Features gives an immediate diagnostic answer by revealing
fungal hyphae. This is particularly characteristic in tinea
Pruritus is the main symptom in most forms of tinea.
Skin lesions usually present with erythema and scaling. versicolor, where the Malassezia furfur appears in a
Various types of tinea presents as following: "spaghetti and meatballs" pattern. Wood light (UV light)
Tinea capitis: Scalp is involved and presents as examination in tinea capitis shows fluoresces if
alopecia, with hairs breaking at the scalp surface. Microsporum species is the cause and do not fluoresces
Tinea tonsurans is the cause of >90% of cases of tinea if Trihophyton species is the cause.
capitis. Kerion, an inflamed, boggy granuloma of
scalp may be present. Treatment
Tinea manuum: Involves palms and finger webs and
usually occurs in association with tinea pedis, Fungal infections may be treated with topical agents
affecting only one hand. (ketoconazole, clotrimazole, miconazole). Topical therapy
Tinea pedis: Infection of the toe webs and plantar is ineffective in treating tinea of the hair and nails. For
surface, affecting usually only one foot. Toe-web them oral terbinafine or itraconazole are most efficacious.
scaling, fissuring, and maceration along with vesicles, Therapy of 6 weeks for fingernails and 12 weeks for
pustules, and bullae may be present. It is mostly toenails is used. Terbinafine is potentially hepatotoxic,
associated with activities that cause excessive and it is important to periodically check liver function
sweating. tests when it is used.
Tinea corporis: Usually involves exposed skin of the Effective topical agents for tinea versicolor include
trunk and extremities and is characterized by annular selenium sulfide, sodium sulfacetamide, ciclopirox
scaly plaques with raised edges, pustules, and olamine as well as azole and allylamine antifungals.
vesicles.
Tinea cruris (jock itch): Infection of the groin and Candidiasis
pubic region and is characterized by erythematous
lesions with central clearing and raised borders. It is The range of infection with Candida species varies from
more common in obese males. a benign local mucosal membrane infection to dissemi-
Tinea barbae: Affects beard and neck area. Erythema, nated disease. Severe disease is typically seen in
scaling, and pustules are present. immunocompromised states.
194 The Definitive Review of Medicine for USMLE
It is an extremely severe, life-threatening infection of and clindamycin with/without naficillin and removal of
the skin. It starts as a cellulitis that dissects into the cause of infection.
fascial planes of the skin. Diabetic patient are more '99er'-Ecthyma gangrenosum- involves hemorrhage,
predisposed towards its development. necrosis, and ulceration in presence of Pseudomonas
infection. Treatment involves IV aminoglycosides along
Clinical Features with piperacillin/ceftazidine/cefepime. No surgical
debridement required.
Typically there is a sudden onset of pain, erythema and
'99er'-Pyoderma gangrenosum (PG) - Pain is the
swelling at the site of trauma or recent surgery. Over the
predominant historical complaint and arthralgias and
next several hours to days, the local pain progresses to
malaise may often be present. Classic PG is typically seen
anesthesia and infection gives way to dusky or purplish
in ulcerative colitis and is characterized by a deep
skin discoloration near the site of insult. Sensory along
ulceration with a violaceous borders, typically on the legs.
with skin changes (Diagnosis clincher). Patients have an
Atypical PG has a vesiculopustular "juicy" component
elevated creatinine phosphate. Air may be seen in
and usually occurs on the dorsal surface of the hands, or
involved tissue on imaging. Although the following
extensor parts of the forearms. Topical therapies include
features can occur with cellulitis, they usually suggest
local wound care and dressings, and superpotent topical
NF instead:
corticosteroids. Systemic therapies include
Rapid progression
corticosteroids, cyclosporine, mycophenolate mofetil,
Poor therapeutic response
azathioprine, dapsone, tacrolimus etc. IV therapy may
Blistering necrosis
also be given.
Palpable crepitus
Cyanosis
Extreme local tenderness Scabies
High temperature The arthropod Sarcoptes scabiei var hominis causes an
Portal of entry into skin. intensely pruritic and highly contagious skin infestation
with superficial burrows. It is transmitted by skin-to-skin
Treatment contact.
Surgical exploration, debridement, and hemodynamic
support should be provided. The best empiric antibiotics Clinical Features
are the beta-Iactam/beta-Iactamase combination It is characterized by extreme pruritus, burrows, and
medications (ampicillin/sulbactam, ticarcillin/ papules commonly found on flexor surfaces of wrists,
cIavulanate). If there is a definite diagnosis of group A finger webs, axillary folds, elbows, genitals of the males
Streptococcus pyogenes, then treat with clindamycin and and areola of the breast in women.
penicillin. 'Skin popping'-injecting narcotic analgesics
directly into the skin for pain relief may be required. This Diagnosis
is done due to lack of intravenous access.
By demonstrating mites, mite pellets, eggs, eggshell
'99er'-Paronychia- It is a superficial infection of
fragments in scrapings, after placing mineral oil drop
epithelium lateral to the nail plate. The acute painful
purulent infection is most frequently caused by directly over burrows.
staphylococci. The patient's condition and discomfort are
markedly improved by a simple drainage procedure or Treatment
anti-staphylococcal antibiotics like dicloxacillin or Topical options include permethrin, lindane and systemic
cephalexin may also be used. drug ivermectin is used in severe cases. Permethrin is
'99er'-Toxic shock syndrome- is because of S. aureus the drug of choice in the US. Treatment should be
production of exotoxin. It is usually acquired by the use prescribed for patients, household members, and close
of tampons (typically in boards), sponges, and surgical personal contacts.
wound infections. Clinically it will present with hypo-
tension, mucosal changes, fever, desquamative rash on
Pediculosis
hands and feet. Other systems may also be involved.
Treatment involves fluid replacement (up to 20L/day) Skin infestation by lice is called pediculosis.
Dermatology 197
Medication includes permethrin, lindane, malathion, or Irregular border Smooth regular border
Grow rapidly in size Do not grow rapidly
mercuric oxide ointment. Nits are best removed with a
Diameter usually > 1cm Diameter usually < 1cm
very fine comb. Variegated appearance Homogenous in color
Change in appearance Doesn't change
Warts
These are benign proliferations of skin and mucosa
caused by the human papilloma virus (HPV). They are
transmitted by direct or indirect contact. Genital warts
Fig. 11.2: Molluscum contagiosum are also caused by HPV.
(For color version see Plate 1)
Clinical Features
Molluscum Contagiosum
Seen commonly in older children, they are of various
It is caused by a member of the poxvirus group shapes like filliform, flat, deep palmoplantar (myrmecia),
mosaic, cystic etc. The common warts on examination
Clinical Features appear as hyperkeratotic papules with a rough, irregular
surface and may be 1 mm to 1 cm in size. Though they
Molluscum contagiosum usually presents as single or
can occur on any part of the body, most commonly they
multiple (usually no more than 20) discrete, painless,
are seen on the hands and knees.
waxy, skin colored papules that classically have a central
umbilication (diagnosis clincher). If superinfection takes
Diagnosis
place, the lesions may present as pustules, possibly
painful, with erythema and induration. If children It is usually clinical.
present with genital lesions, sexual abuse should be
considered. Patients may be able to recall contact with Treatment
an infected sexual partner, family member, or other
It can be difficult with frequent failures and recurrences.
person.
Many warts resolve spontaneously within a few years.
Salicylic acid is a first-line therapy used to treat warts.
Diagnosis
Many other topical agents that can be used are
The diagnosis of molluscum contagiosum is clinically trichloroacetic acid, cantharidin, podophyllin,
based upon the appearance and locations of the lesions. imiquimod, cidofovir, etc.
198 The Definitive Review of Medicine for USMLE
Seborrheic Keratoses
It is a hyperpigmented benign lesion presenting in variety
of clinical appearances and occurs in the elderly. It
develops from the proliferation of epidermal cells.
Although no specific etiologic factors have been
identified, they occur more frequently in sunlight-
exposed areas.
Clinical Features
Initially one or more sharply defined, light brown, flat
lesions develop with a velvety to finely verrucous
surface. The lesions can grow to several centimeters or
Fig. 11.3: Acanthosis nigricans at a flexural site more and with time become thicker and have an
(For color version see Plate 2)
appearance of being stuck on the skin surface (Diagnosis
clincher).
Treatment
Ammonium lactate, liquid nitrogen and alpha hydroxy
acids have been reported to reduce the height of
seborrheic keratoses. Superficial lesions can be treated
by carefully applying pure trichloroacetic acid and
repeating if the full thickness is not removed on the first
treatment.
Actinic Keratoses
It is a UV light induced precancerous lesion of the skin
that may progress to invasive squamous cell carcinoma
and is by far the most common lesion with malignant
potential to arise on the skin. The lesion occurs more
Fig. 11.4: Seborrheic keratoses often in those with light skin color and is present on sun
(For color version see Plate 2) exposed parts.
Dermatology 199
Clinical Features Asymmetry: Half the lesion does not match the other
half.
Initially they feel similar to rubbing sandpaper (diagnosis
Border irregularity: The edges are ragged, notched,
clincher). With time, the lesions enlarge, usually
or blurred.
becoming red and scaly. Although the lesions are usually
Color variegation: Pigmentation is not uniform and
asymptomatic, they can be tender to the touch. Most
may display shades of tan, brown, or black; white,
are only 3-10 mm, but they may enlarge to several
reddish, or blue discoloration is of particular concern.
centimeters.
Diameter: A diameter greater than 6 mm is
characteristic any growth in a nevus warrants an
Treatment
evaluation.
Sunscreen should be used to prevent their progression Evolving: Changes in the lesion over time are
and recurrence. Four drugs have been approved by characteristic (diagnosis clincher).
USFDA for its treatment and they are topical 5-
fluorouracil (5-FU), 5% imiquimod cream, topical Diagnosis
diclofenac gel, and photodynamic therapy (PDT) with
topical delta-aminolevulinic acid. They can also be Biopsy diagnosis is best performed with a full-thickness
surgically removed. sample because tumor thickness/depth is by far the most
important prognostic factor. Cells often stain immuno-
MALIGNANT DISEASES histochemically for S-100.
Melanoma Treatment
Melanoma is a malignancy of pigment-producing cells Melanoma is removed by excision. The size of the margin
(melanocytes) located predominantly in the skin and it is determined by the thickness of the tumor.
causes the greatest number of skin cancer-related deaths
worldwide and also is the fastest rising cancer in terms Table 11.4
of occurrence in US. Melanoma is histologically divided
Tumor thickness Surgical margin
into superficial spreading melanoma (most common),
nodular melanoma, lentigo maligna melanoma, and acral In situ 0.5 cm
lentiginous melanoma (palms, soles of feet, and nail < 1mm 1 cm
1-2 mm 2 cm
beds).
> 2mm 2-3 cm
Treatment
Outpatient topical therapy is the first-line approach in
the treatment of plaque psoriasis. A number of topical
treatments like corticosteroids (for mild localized
diseases), coal tar, anthralin (both in severe disease),
calcipotriene, tazarotene (both are alternative for tar and
steroids) are available. For mild, localized, thick plaque
psoriasis, high potency steroids like betamethasone
should be used. Low potency steroids are used for lesions
on face and intertriginous areas. Salicylic acid is used to
remove heaped-up collections of scaly material so that
the other therapies can make contact. Initiate
phototherapy only in the presence of extensive and
widespread disease (>30% area) or in presence of
resistance to topical treatment. UVB light exposure 3
times a week is recommended regimen. It may be used
following topical coal tar application (Goeckerman
Fig. 11.5: Plaque psoriasis with fine white regimen) or anthralin application following a tar bath
scales over an erythematous base and UVB treatment (Ingram method). PUVA (psoralen
(For color version see Plate 2) and UVA) is used if UVB doesn't work. Initiate systemic
treatment with methotrexate only after both topical
Psoriasis treatments and phototherapy have been unsuccessful and
disease is extremely severe. The newest therapy by
It is a noncontagious skin disorder of unknown etiology immunomodulatory biologic agents such as etanercept,
with a probable genetic predisposition that most and infliximab is also being tested and used.
commonly appears as inflamed, edematous skin lesions Methotrexate is preferred treatment for patients with
covered with a silvery white scale. arthritis and nail involvement. Penicillin or cephalosporins
should be given in Guttate psoriasis and Rifampin should
Clinical Features be given if they fail to show effect.
According to type are: '99er'-Drugs that increases psoriasi include anti-
Plaque psoriasis: raised inflamed lesions covered malarial drugs, NSAIDs, ACE inhibitors, lithium, -
with a silvery white scale commonly on the extensor blockers.
202 The Definitive Review of Medicine for USMLE
Table 11.5
Pemphigus vulgaris Bullous pemphigoid
Antigen involved Desmoglein 1 and 3 Hemidesmosomal BP antigens
Age of patient 30-40 Elderly (70-80)
Location in skin Within epidermis At dermo-epidermal junction
Distribution Prominently oral Rarely oral
Bullae Very thin walled, hence prone to easy
breakage. Thick walled and less likely to rupture
Severity Very severe and life-threatening Much less severity and mortality
condition
Nikolsky sign (removal of skin by Positive Negative
little pressure of finger)
Immunofluorescence pattern Lacelike/fishnet Linear
Treatment
Systemic steroids are mainstay of treatment in both
diseases. If they are not effective or tolerated well,
antibiotics like azathioprine, cyclophosphamide,
mycophenolate (pemphigus) or tetracycline, erythro-
mycin (pemphigoid) may be used.
'99er'-Pemphigus foliaceus- is much more superficial
with no intact bullae seen as they break so easily. No oral
lesions like pemphigus are seen. Diagnosis and treatment
are similar.
'99er'-Nikolsky sign- is also seen in staphylococcal
scalded skin syndrome, and toxic epidermal necrolysis.
Fig. 11.6: Bullous pemphigoid
(For color version see Plate 2) Porphyria Cutanea Tarda
It is a disorder of porphyrin metabolism in which activity
of enzyme uroporphyrinogen decarboxylase is deficient
that results in a photosensitivity due to high accumulation
of porphyrins. It is often associated with history of liver
disease, chronic hepatitis C, OCPs, diabetes, hemochro-
matosis (iron deposition in liver), or alcoholism.
Clinical Features
The most common initial symptoms are cutaneous
fragility and fragile, nonhealing blisters seen on the sun-
exposed parts of the body (diagnosis clincher) such as
the backs of the hands and the face. Increase in hair
growth and hypertrichosis, usually over temporal and
Fig. 11.7: Pemphigus vulgaris
malar facial areas, along with hyperpigmentation are
(For color version see Plate 2)
noted. Urine discoloration may also be seen.
Diagnosis Diagnosis
Skin biopsy and immunofuorescence to detect specific The most accurate test for diagnosis is level of urinary
antibodies are the most accurate tests for both conditions. uroporphyrins, which are highly elevated. The excess
Dermatology 205
Clinical Features
Generally, muscle is the least resistant and will necrose
prior to skin breakdown. They have been classified into
various stages:
Stage I: Blanchable erythema that with continued
pressure creates erythema that becomes nonblanch-
able with pressure. This may be the first outward
Fig. 11.8: Acne on forehead of a teenager
sign of tissue destruction and finally, the skin may
(For color version see Plate 2)
appear white from ischemia.
Stage II: Partial-thickness loss of skin involving Acne
epidermis and possibly dermis that presents as an
abrasion, blister, or superficial ulceration. It presents as noninflammatory follicular papules or
Stage III: Full-thickness loss of skin with extension into comedones. More severe forms are characterized by
subcutaneous tissue but not through the underlying inflammatory papules, pustules, and nodules. Acne is
fascia. This lesion presents as a crater with or without more common in girls, but boys have more severe disease.
undermining of adjacent tissue. Acne vulgaris affects the areas of skin with the densest
population of sebaceous follicles like face, the upper part
Stage IV: Full-thickness loss of skin and
of the chest, and the back. Propionibacterium acnes is
subcutaneous tissue and extension into muscle, bone,
contributing pathogen.
tendon, or joint capsule. Osteomyelitis, sinus tracts,
dislocations, or pathologic fractures may be present.
Clinical Features
Pressure sore infection is suggested by the presence
of necrotic tissue, wound edge erythema, purulent A comedone is a whitehead (closed comedone) or a
discharge, and a foul odor. blackhead (open comedone) without any clinical signs
206 The Definitive Review of Medicine for USMLE
of inflammation. Papules and pustules are raised bumps used. Flushing of face if not acceptable to patient may be
with obvious inflammation and the discharge though controlled using clonidine or -blockers. Initial drug
purulent, is odorless. therapy is topical metronidazole with/without oral
antibiotic. If symptoms persist or if ocular symptoms are
Treatment present, than oral antibiotics like tetracycline, or tretinoin
Mild disease is first treated with benzoyl peroxide, then cream may be used for remission. For maintenance,
topical antibiotics (clindamycin, erythromycin). If these topical metronidazole may be used.
measures are ineffective than topical retinoids are
applied. Isotretinoin (strong teratogen) is a systemic HAIR DISEASES
retinoid that is highly effective in the treatment of severe, Alopecia Areata
recalcitrant acne vulgaris. Pregnancy is contraindicated
in those who are on treatment with topical or oral It is a recurrent, autoimmune, nonscarring type of hair
retinoid. They may also cause dry skin and mucosae, loss that can affect any hair-bearing area. Presence of
muscle and joint pain, hypertriglyceridemia, and exclamation point hairs, i.e. hairs tapered near proximal
abnormal LFT. Oral antibiotics (tetracycline, minocycline, end is pathognomonic (diagnosis clincher) but is not
clindamycin) may also be used in severe cases. always found. It is often associated with Addisons
Acne conglobata is an uncommon and unusually disease, SLE, pernicious anemia and Hashimoto
severe form of acne. It is characterized by burrowing and thyroiditis, syphilis, and presence of antimicrosomal
interconnecting abscesses and irregular scars often antibody. It may also be seen after chemotherapy. It is
producing pronounced disfigurement (diagnosis treated by localized steroid injection into the area of hair
clincher). The cysts contain foul-smelling seropurulent loss. But it may recur even after successful treatment.
material that returns after drainage. They are usually
found on chest, shoulders, thighs, face, back, buttocks, Telogen Effluvium
and upper arms. Treatment of choice is oral isotretinoin.
Systemic steroids may also be added. It is a reactive process caused by a metabolic or hormonal
'99er'-Acne has not been proved to be related to any stress or by medications, which causes acute onsets
food, but if the patient makes any such relation, than you nonscarring alopecia characterized by diffuse hair
can try discontinuance of that presumably causative food. shedding. There should be no areas of total alopecia in a
patient with telogen effluvium. Treatment usually is
Rosacea limited to reassurance and correction of underlying stress
or disease.
It is a chronic acneiform (mimics acne) condition 99er-Trichotillomania - it is a psychiatric condition
characterized by vascular dilation in central face. It is
of compulsively pulling one's hair. In this disorder,
more common in fair skinned people, those with light
patients have unilateral hair loss, irregular borders of bald
hairs and eyes, and those who have frequent flushing.
patches and continuously growing hairs.
'99er'-Androgenetic Alopecia- FDA recommended
Clinical Features
drugs for its treatment are only minoxidil and finasteride
Patient may present with frequent flushing, elicited by (used only in men).
spicy food, emotional reactions and alcohol (diagnosis '99er'-Hair with split ends- can be due to toxic/
clincher). Lesions are erythematous, inflammatory chemical reaction causing hair loss. Lithium is known to
papules on forehead, nose, cheeks, and chin. Rhino- cause rarefaction of hairs and widespread hair loss
phyma may also be seen in late stages of the disease. It is without affecting the hair itself. Allergic reactions affect
associated with ocular symptoms like burning, foreign scalp rather than hairs.
body sensation, conjunctivitis, blepharitis, keratitis, '99er'-Nevus of Ota- is an oculodermal melanocytosis.
recurrent chalazion, and episcleritis. Typical lesions present as confluent bluish gray macules
with accompanying scleral pigmentation on one side of
Treatment face, which is affected by insomnia, emotional events,
The goal is to control rather than cure. Skin should be extreme of weathers, menstrual changes. Area supplied
kept clean with mild cleansers. Benzoyl peroxide may be by trigeminal nerve is typically involved and is found
Dermatology 207
commonly in people of Japanese descent. Eyes and CNS '99er'-Pearly penile papaules- are pearly white, dome-
may also be involved. shaped papules occurring circumferentially on the
'99er'-Keloids: is an overgrowth of scar tissue after coronal margin and sulcus of glans penis. Usually present
an injury and is most frequently seen in blacks. It is around the age of 20-30s. Patient might be concerned that
classically found on upper back, chest and deltoid area. it is condylomata or might have been referred as treat-
It is treated with intralesional steroids. If it fails or is ment resistant veneral warts. This is not an uncommon
contraindicated, scalpel/laser excision is next step. finding and no treatment is required.
Cryosurgery if used, may lead to hypopigmentation. '99er'-Arsenical keratoses- is due to long-term
'99er'-Tattoo- removal may be by lasers which lead ingestion of inorganic trivalent form of arsenic. Typical
to scar mark, discoloration, or dermabrasion. findings are skin and nail changes, such as punctuate
hyperkeratosis of palms and soles, 'raindrop'
'99er'-Nummular eczema- is characterized by coin
hyperpigmentation, Mees lines (transverse white striae
shaped lesions, which are covered by uniform, scaly
on finger nails), and exfoliative dermatitis. Patient may
crust that may or may not itch. It is usually seen in adults
complain of sensory and motor neuropathy. High intake
with dry skin. It only requires symptomatic treat-
of arsenic in water may also lead to 'blackfoot disease'
ment of pruritus, if severe, as the lesion resolves
(a gangrenous condition). These patients are more prone
spontaneously. to deveop basal cell carcinoma.
Chapter
12 Miscellaneous Topics
CANCER SCREENING
Table 12.1
Cancer Recommendations
Breast Monthly self examination, annual exam by physician. Mammography each year after age 40-50 or earlier if
there is positive family history at younger age
Cervical Annual Pap smear after age of 18 or at onset of sexual history. After three consecutive normal Pap smears, the
screening interval can be to every 3 years
Colon Hemoccult annually, flexible sigmoidoscopy every 3-5 years and colonoscopy every 10 years after >50 years of
age. If a first degree relative has colon cancer than begin screening at 40 or 10 years younger than the age at
which relative was diagnosed, whichever is first.
Herbal Drugs
These are drugs that are not recommended by FDA but are popularly used in some ethnicities and particular regions.
Table 12.2
Drug Indication Adverse effect
Saw palmetto Benign hypertrophy of prostate Hypertension
Kava anxiety and insomnia Liver injury. Kava taken with alcohol, BDZ or
other sedative-potentiates their effect.
Gingko (antioxidant) Mild memory loss, dementia, PVD, muscular Bleeding
degeneration. Increases cerebral blood supply.
Garlic Hypercholesterolemia Bleeding and platelet dysfunction
St. johns wort Depression GI distress, fatigue, dizziness, dry mouth. In long
term use, it may cause anorgasmia, urinary
frequency and swelling. Photosensitization in HIV
positive patients.
Aristolochic acid Chinese weight loss medications Fulminant tubulointerstitial disease
Ginseng Anti stress, aphrodisiac. Steven Johnson syndrome and psychosis.
Aconite In witch craft Cardiotoxicity
Horse chest nut venous insufficiency/chronic venous stasis Inhibits platelet aggregation and leads to
bleeding in patients already on anti coagulation.
Table 12.3
Drugs Adverse effects
Acetaminophen Liver toxicity (in high doses)
Phenytoin Folate deficiency, teratogen, hirsutism
Bupropion Seizures
Aspirin GI bleeding, hypersensitivity
Trazodone Priapism
Contd...
210 The Definitive Review of Medicine for USMLE
Contd...
Table 12.4
Condition Screening test Confirmatory (if required)
Aortic aneurysm/dissection/tear CT with contrast Angiography
Carotid stenosis Duplex/MRA Angiography
Chest trauma CXR* CT with contrast
Chest mass CXR CT with contrast
Pneumonia CXR
Pulmonary embolism V/P scan CT with contrast/Pulmonary
arteriography
Hemoptysis CXR CT with contrast/bronchoscopy
Brain tumor MRI/CT with contrast
Multiple sclerosis MRI with contrast
Skull fracture CT
Head trauma CT without contrast
Intracranial hemorrhage CT without contrast
Acute stroke CT without contrast
Unknown GI bleeding Nuclear tag scanning
Upper GI bleed (hematemesis, PUD) Upper barium series or endoscopy Endoscopy
Lower GI bleed Barium enema or endoscopy Endoscopy
Bowel perforation AXR# Laparoscopy/CT
Esophageal tear Gastrografin imaging or endoscopy Endoscopy
Esophageal obstruction Barium study or endoscopy Endoscopy
Intestinal obstruction AXR CT with contrast
Abdominal trauma CT with contrast Laparoscopy
Cholelithiasis Ultrasound
Choledocholithiasis Ultrasound ERCP
Cholecystitis Ultrasound HIDA scan
Appendicitis AXR, then ultrasound/CT with contrast Laparoscopy
Diverticulitis CT with contrast
Hematuria CT Cystoscopy
Nephrolithiasis CXR, IVP CT without contrast
Hydronephrosis Ultrasound/CT
Fracture X-Ray
Bone metastasis Bone scan
Arthritis X-Ray
Osteomyelitis X-Ray Bone scan/MRI
* Chest X-ray
# Abdominal X-ray
Index