EUH Dressler Case Conference: In chest x-rays, what is the water bottle sign?

Bottom Line: In patients with pericardial effusion, the water bottle sign appears when the chest x-ray’s cardiac silhouette has a globular shape that looks like a water bottle as the result of slowly accumulating fluid. In the screenshot from YouTube below, the four images show a normal chest x-ray (top left corner), a patient with cardiomegaly (lower right corner), and a chest x-ray with a water bottle sign (lower right corner). The water bottle shape appears in the upper right corner.
water bottle sign

Reference for Image: Hammadshams. Chest X-Ray – Cardiomegaly or No Cardiomegaly – Water Bottle Sign. Accessed January 23, 2018.

Posted in Diagnosis, EUH | Tagged

EUH Dressler Case Conference: Review of cardiac sarcoidosis

Bottom Line: Increased awareness and diagnostic techniques are the primary reasons for the exponential increase in the prevalence of cardiac sarcoidosis during the last decade. More evidence is needed to determine optimal management. First-line treatment is corticosteroids; authors recommend also using immunosuppressive therapy. For either primary or secondary prevention of ventricular arrhythmias and cardiac death, implantable-cardioverter defibrillators (ICDs) should be a consideration for all patients.

Reference: Young L, Sperry BW, Hachamovitch R. Update on treatment in cardiac sarcoidosisCurr Treat Options Cardiovasc Med. 2017 Jun.

Posted in Background question, EUH, Therapy | Tagged

Krakow Conference: What are therapy options for DRESS syndrome?

Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), is a rare, severe cutaneous adverse reaction characterised by fever, rash, lymphadenopathy, eosinophilia and/or other leukocyte abnormalities, and internal organ involvement and often has a relapsing–remitting course despite withdrawal of the drug.

Fernando, S.L. (2013). Drug-reaction eosinophilia and systematic symptoms and drug-induced hypersensitivity syndrome. Australasian Journal of Dermatology, 55(1), 15-23. .

The French Society of Dermatology formulated guidelines on the management of DRESS/DIHS as follows:

1. Absence of signs of severity: topical corticosteroids, emollients and H1-antihistamines.

2. Presence of signs of severity (transaminases > fivefold normal, renal impairment, pneumonia, haemophagocytosis and cardiac involvement): prednisone 1 mg/kg per day.

3. Life-threatening signs: (haemophagocytosis with bone marrow failure, encephalitis, severe hepatitis, renal failure, respiratory failure): prednisone and i.v. Ig 2 g/kg over 5 days.

4. Presence of signs of severity with confirmation of major viral reactivation: prednisone and valgangciclovir +/− i.v. Ig

Posted in EUH, Teaching pearls

Kokko Conference: Is Vitamin B12 deficiency one of the etiological causes of pancytopenia?

The Bottom Line: The etiological causes of pancytopenia vary depends on patients’ age, gender, country, and other conditions. Vitamin B12 deficiency is the most common treatable cause of pancytopenia.


Yokuş O, Gedik H. Etiological causes of pancytopenia: A report of 137 cases. Avicenna J Med. 2016 Oct-Dec;6(4):109-112.

ARTICLE mentioned in Conference:

Stabler, SP. Clinical practice. Vitamin B12 deficiencyN Engl J Med. 2013 Jan 10;368(2):149-60. doi: 10.1056/NEJMcp1113996.

Posted in Applying evidence, Grady

EUH Hunt Conference: Residents’ “Pathways Service” to link patient care to scientific inquiry

Bottom Line: The authors created a “Pathways Service” to link patient care to scientific inquiry by attempting to fill gaps in knowledge regarding the biology behind patients’ medical problems. Residents refer patients on their service to the program “if they have an extreme or unusual disease phenotype that no one has been able to explain adequately and if the disease process appears to reflect a fundamental pathophysiological problem.” Patients are chosen if a determination is made that there is a “potential for elucidating the underlying pathophysiology.” Residents on the Pathways rotation, along with the faculty advisor, “meet the patient, review data, and formulate pathophysiological hypotheses that they discuss with basic and clinical scientists from around the world.” The residents present the case at a Pathways conference. “After debate about the possible underlying mechanisms and potential experiments, the team agrees on recommendations for further clinical workup and a road map outlining feasible scientific explorations that may advance understanding of the fundamental problem.”

Armstrong K, Ranganathan R, Fishman M. Toward a culture of scientific inquiry – the role of medical teaching services N Engl J Med. 2018 Jan 4;378(1):1-3.

Posted in EUH, Miscellaneous | Tagged

EUH Hunt Conference: Review of Meigs’ Syndrome

Bottom Line: Meigs’ syndrome is also known as Meigs syndrome or Demons-Meigs syndrome. It is characterized by a triad of ascites, pleural effusion, and benign ovarian fibroma, which is a rare triad. “Meigs syndrome…is a diagnosis of exclusion only after ovarian carcinoma is ruled out. The presentation of symptoms and radiographic findings mimics that of metastatic ovarian cancer, creating a significant clinical challenge….The treatment is exploratory laparotomy that includes biopsy of the ovarian mass, lymph node biopsies, biopsy of omentum, and pelvic washings. Unilateral salpingo-oophorectomy is performed in women of reproductive age, whereas total hysterectomy is preferred in postmenopausal women. The prognosis of Meigs syndrome is good and <1% of fibromas progress to fibrosarcoma. The pleural effusion and ascites resolve within a few weeks after tumor resection. We favor the use of chest ultrasound to follow pleural effusion progression, as it is superior to chest x-rays in identifying residual pleural effusion and can detect amounts as small as 3 to 5 mL.” The article reports a case of a patient with recurrent pleural effusions and an ovarian mass. It describes the case in detail and reviews the literature on Meigs syndrome.

Riker D, Goba D. Ovarian mass, pleural effusion, and ascites: revisiting Meigs syndrome. J Bronchology Interv Pulmonol. 2013 Jan;20(1):48-51.

Posted in Background question, EUH, Prognosis, Therapy | Tagged ,

EUH Hunt Conference: What is the sensitivity of cytology tests of pleural effusion and ascites?

Bottom Line: Sensitivity of ascitic cytology is approximately 60%, and the sensitivity of pleural effusion cytology is approximately 50%.


Karoo RO, Lloyd TD, Garcea G, Redway HD, Robertson GS. How valuable is ascitic cytology in the detection and managent of malignancyPostgrad Med. 2003 May;79(931):292-294. Study included 276 samples.

Motherby H, Nadjari B, Friegel P, Kohaus J, Ramp U, Bocking A. Diagnostic accuracy of effusion cytology. Diagn Cytopathol. 1999 Jun;20(6):350-357. Study included 300 pleural effusions and 300 ascitic effusions and provides sensitivity for both types of effusions.


Posted in Diagnosis, EUH | Tagged ,