Thursday, October 27, 2011

Infectious Disease, Week 3

Things are still going well - this week we have another student hanging out with us.  He's a fourth year from my school, and apparently one of the top of their class - his board scores are probably 98th percentile and he's getting interviews for residencies in places that are competitive even for MD students, and normally impossible for DO students.  Needless to say it's a mixed bag - on the one hand now I have someone who has a ton of information who I can learn from and get tips for fourth year.  On the other hand, he's a genius - which is kind of intimidating.  On the plus side, he doesn't have an insufferable ego and is pleasant and nice, so that's good.  He's also very tall, about as tall as my preceptor and they are both over 6 feet tall, so I feel pretty short compared to the two of them.

We have been talking a lot about rickettsial diseases lately.  We had a patient come into clinic who was previously diagnosed with Lyme disease, Batonella, a couple other rickettsial diseases based on a tick bite 20 years ago and some doctor wanted her to go down to Monterey and pay for a 45 day infusion of antibiotics.  We all agreed, after the patient left, that she's probably being scammed - it's really a shame, because diseases like Lyme disease CAN have a chronic and nonspecific presentation - occasional fever, joint pain and stiffness, abdominal and cardiac problems.  When diseases have nonspecific presentations like that, the rate of false positives and hypochondriasis and money making by shady doctors goes through the roof.  

As far as interesting patients - our necrotizing fasciitis patient from the prison had had a surgery to debride his infected arm, but it wasn't enough and the bug was extremely resistant to antibiotics.  He developed a classic necrotizing fasciitis rash across his chest, and had tense bullae as well.  He died later that day.  We had another patient who was brought in for various reasons but one was vancomycin-resistant enterococcus endocarditis complicated by aspiration pneumonia (where you inhale stomach contents along with acid and possible bacteria and it damages your lungs or predisposes to infection).  The endocarditis was challenging because it was resistant to vancomycin, as well as a bunch of other major antibiotics.  We were treating with linezolid, but the course of treatment for endocarditis requires 6 weeks of antibiotics and we can't use linezolid that long or you start damaging the optic nerves.  Also, Daptomycin was considered but it is inactivated by lung surfactant so there wouldn't be good coverage of the possible aspiration pneumonia.  That patient also died later.  

Today is another round of patients in the ICU, then rounding on inpatients, then we go to another hospital to check up on patients and talk to the pharmacy staff about antibiotics.  Yesterday was a long day, hopefully today will go shorter.

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