EUHM Report: What is the etiology of Streptococcus anginosus?

The S anginosus group, often referred to as Streptococcus milleri , are commensals of the oropharyngeal, GI, and genitourinary microflora that can cause invasive  pyogenic infections in various sites. While more commonly associated with CNS, abdominal, head and neck, bloodstream, and thoracic infections, the three species that make up S anginosus have been associated with differing clinical manifestations.

Sunwoo, Bernie Y, and Wallace T Miller. “Streptococcus Anginosus Infections: Crossing Tissue Planes.” Chest. 146, no. 4 (2014): E121-125.

While more commonly associated with CNS, abdominal, head and neck, bloodstream, and thoracic infections, the three species that make up S anginosus have been associated with differing clinical manifestation.  The S anginosus group of organisms is known to be highly virulent and rapidly progressive, and it is not surprising that they might cross tissue planes.  Given the potential utility of radiographic extension across tissue planes in raising the differential of S anginosus , further research on the radiographic presentations of thoracic S anginosus is needed.


EUHM Report: Acute and subacute shortness of breath in patients with Pneumocystis Jirovecii Pneumonia

HIV-infected patients usually develop a subacute course of disease, while non-HIV infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever.

Salzer, Helmut J F, Guido Schäfer, Martin Hoenigl, Gunar Günther, Christian Hoffmann, Barbara Kalsdorf, Alexandre Alanio, and Christoph Lange. “Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis Jirovecii Pneumonia.” Respiration. 96, no. 1 (2018): 52-65.

The diagnosis of PCP is mostly a presumptive diagnosis in resource-limited settings. Clinical signs and symptoms, particularly dyspnea, fever, dry cough, and hypoxia in absence of an alternative diagnosis in an immunocompromised patient with a CD4+ T lymphocyte count <200 cells/mL and concurrent radiological changes lead to the initiation of PCP treatment

Table 1. Disease characteristics of PCP in HIV-positive patients compared to patients with other reasons of immunosuppression (page 4)



EUHM Report: What are the common presentations of hepatic abscess?

The Bottom Line: Most cases of hepatic abscess present at advanced age. One study reported a mean age > 57 years.19 This finding suggests that older individuals are more susceptible to bacterial infection and thus abscess formation.  Most of the symptoms of hepatic abscess are due to infection and are nonspecific and it can be quite difficult to diagnose in a timely manner.  The most commonly reported signs and symptoms (Table 2. Page 162) include fever in most but not all cases, abdominal pain, and hypotension

Mavilia, M. G., Molina, M., & Wu, G. Y. (2016). The Evolving Nature of Hepatic Abscess: A Review. Journal of Clinical and Translational Hepatology, 4(2), 158–168.

Hepatic abscess remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system.  Hepatic abscess can be defined as an encapsulated collection of suppurative material within the liver parenchyma, which may be infected by bacterial, fungal, and/or parasitic micro-organisms

EUHM Report: What syndromes are associated with Pulse Temperature Disassociation?

The Bottom Line: The mechanisms for fever-induced bradycardia are not completely understood. It is well known that many infectious agents can cause acute myocarditis and induce cardiac conduction abnormalities. One study suggested that relative bradycardia due to a specific disease has no predictive value in making a diagnosis. However, another  suggests that relative bradycardia in a single patient can be helpful in arriving at a tentative diagnosis.

Mittal J, Estiverne C, Kothari N, Reddi A. Fever and Relative Bradycardia: A Case Presentation and Review of the Literature. Int J Case Rep Short Rev. 2015;1(1): 004-008.

In many noninfectious and infectious conditions, the heart rate does not increase with a rise in temperature. This phenomenon is called pulse-temperature deficit which many clinicians refer to as relative bradycardia. A caveat to this rule is that a patient must have a temperature of at least 102 F in order to better appreciate this pulse temperature relationship

EUHM Resident Report: Prevalence of Chagas disease in the United States.

The Bottom Line: In the United States, little evidence is available to document Chagas disease prevalence, assess congenital and vector-borne transmission risk, and quantify the clinical disease burden. Based on immigration estimates for the United States and prevalence estimates in Latin America, more than 300,000 persons with Chagas disease are living in this country; many of these persons do not know that they are infected. An estimated 63–315 babies acquire T. cruzi infection congenitally in the United States every year but most infections go undetected and untreated. Based on these estimates, chagasic cardiomyopathy, which can be prevented through early treatment, affects approximately 30,000–45,000 persons in the United States.

Montgomery, S. P., Starr, M. C., Cantey, P. T., Edwards, M. S., & Meymandi, S. K. (2014). Neglected Parasitic Infections in the United States: Chagas Disease. The American Journal of Tropical Medicine and Hygiene, 90(5), 814–818.

Although an estimated 300,000 persons with Chagas disease live in the United States, little is known about the burden of chagasic heart disease. It is not known how often congenital or vector-borne transmission of T. cruzi occurs in the United States, although it is known that infected mothers and infected vector bugs are found in this country

EUHM Resident Report: What is the relation of bilirubin levels to jaundice abnormalities?

The Bottom Line: Jaundice occurs when there are disruptions along this metabolic pathway, causing  an increase in unconjugated bilirubin (e.g., from increased red blood cell destruction or impaired bilirubin conjugation) or conjugated bilirubin.

Figure 1.  An algorithmic approach to the evaluation of jaundice in adults  page 165

Fargo, M., Grogan, S., & Saguil, A. (n.d.). Evaluation of Jaundice in Adults. American Family Physician., 95(3), 164-168.

Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree.

EUHM Resident Report: Signaling in Stauffer’s Syndrome

The Bottom Line: Against a fundamental contribution for IL-6 in Stauffer’s syndrome is the wide variety of circumstances in which its elevation has no association with inflammatory or cholestatic liver disease. Nevertheless, dysregulated Il-6 acting through disparate signaling cascades is implicated in a variety of autoimmune and inflammatory conditions

Gremida, A., Al-Taee, A., Alcorn, J., & McCarthy, D. (n.d.). Hepatic Dysfunction in Renal Cell Carcinoma: Not What You Think? Digestive Diseases and Sciences., Digestive diseases and sciences. , 2017.

Although the pathophysiology of Stauffer’s syndrome has not been clearly elucidated, tumor overexpression of interleukin 6 (IL-6) is present in 50–80% of patients with RCC and has been suggested as a possible causative factor in one report

EUHM Resident Report: What is the correlation of HSV encephalitis and intracerebral hemorrhage?

The mechanism of hemorrhagic complication in HSV encephalitis is unclear. The possible mechanisms  include small vessel rupture due to vasculitis and transient hypertension caused by increased intracranial pressure. Gyral pattern of the hemorrhage may suggest that the hemorrhagic complication in HSV encephalitis may be due to associated vasculitis

Takeuchi, S., & Takasato, Y. (n.d.). Herpes simplex virus encephalitis complicated by intracerebral hematoma. Neurology India., 59(4), 594-596.

Herpes simplex virus (HSV) encephalitis is the most common cause of sporadic encephalitis, with a mortality of 70% if untreated. Treatment with acyclovir is associated with reduced mortality. Petechial cortical hemorrhages are common in HSV encephalitis, whereas frank hematoma is extremely rare; only 10 cases have been reported in the literature.


Intracerebral hematoma can complicate HSE even when the evolution is favorable. It should be suspected whenever neurologic deterioration appears and should be distinguished from acyclovir resistance and toxicity, since the management of these entities differs substantially.

Rodríguez-Sainz, A., Escalza-Cortina, I., Guio-Carrión, L., Matute-Nieves, A., Gómez-Beldarrain, M., Carbayo-Lozano, G., & Garcia-Monco, J. (2013). Intracerebral hematoma complicating herpes simplex encephalitis. Clinical Neurology and Neurosurgery, 115(10), 2041-2045.

Intracranial bleeding, although infrequent, can complicate the evolution of herpes simplex encephalitis and should be borne in mind since its presence may require neurosurgery. Although its presentation may overlap the encephalitic features, the lack of improvement or the worsening of initial symptoms, particularly during the second week of admission, should lead to this suspicion and to perform a neuroimaging study.


HSV enters the brain through the direct neuronal transmission from the peripheral site to the brain through the trigeminal or olfactory nerve. The usual manifestation of HSE is fever, headache, seizures, and change in mental status evolving over several days. Atypical manifestation includes intracerebral hemorrhage which has been reported mainly in infants and young children. Intracerebral hematoma in HSE in adults is rare. There are some reports of the occurrence of hematoma in HSE in the adults. The exact mechanism of hemorrhage in HSE is unclear. Vasculitis causing small vessel rupture and transient hypertension due to raised intracranial pressure has been proposed for hemorrhage in HSE.

Mahale, R., Mehta, A., Shankar, A., Miryala, A., Acharya, P., & Srinivasa, R. (2016). Bilateral Cerebral Hemorrhage in Herpes Simplex Encephalitis: Rare Occurrence. Journal of Neurosciences in Rural Practice., 7(Suppl 1), S128-S130.

The most frequent cause of sporadic encephalitis is herpes simplex encephalitis (HSE). It carries a mortality of 70% if left untreated. With the usage of acyclovir in the management of HSE and early diagnosis, the mortality rate has been reduced to 19%. Herpes simplex virus (HSV) causes hemorrhagic necrotizing encephalitis involving the frontal and medial temporal lobes. Petechial cortical hemorrhages have been reported in HSE; however, frank hematoma is rare.

EUHM Resident Report: How to handle difficult patient situations?

Difficult encounters are estimated to represent 15 to 30 percent of family physician visits. Factors contributing to these difficult clinical encounters may be related to the physician, patient, situation, or a combination. Physicians can recognize these visits as challenging by acknowledging their feelings of angst or helplessness generated during the conversation. These encounters are also characterized by a disparity between the expectations, perceptions, or actions of the patient and physician

Cannarella Lorenzetti, R., Jacques, C., Donovan, C., Cottrell, S., & Buck, J. (n.d.). Managing difficult encounters: Understanding physician, patient, and situational factors. American Family Physician., 87(6), 419-425.

The patient and physician each bring a frame of reference and set of expectations to an office visit. Empathy helps the physician suspend judgment and foster a relationship in which he or she is perceived as a healer and ally, not just a service provider. Better health outcomes are achieved when the patient and physician have congruent beliefs about who is in control of necessary changes to improve health. A focused assessment may reveal underlying, potentially treatable mental or psychiatric conditions; a history of abuse; or difficult family or social situations

EUHM Resident Report: How is hypokalemia associated with HIV?

The Bottom Line: Adverse events in HIV patients taking tenofovir are relatively rare, postmarketing reports of nephrotoxicity have alerted physicians to other potentially serious outcomes. This study presents a series of 40 patients who developed hypokalemia associated with tenofovir. Identified risk factors included concomitant ritonavir or didanosine use, a lower weight and longer duration of tenofovir use.

References: Cirino, C., & Kan, V. (n.d.). Hypokalemia in HIV patients on tenofovirAIDS.,20(12), 1671-1673.

Summary: Table 1. Summary of demographic and clinical data from our patient and 39 individual safety reports for hypokalemia on tenofovir.

The overall incidence of toxicity with tenofovir is low. Risk factors of developing renal insufficiency or failure while on tenofovir include those with low body weight, baseline renal insufficiency, or regimens containing ritonavir and didanosine.