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commit 3c296ea2399bb966119f07e5a6ff305f5ac000b4
parent cca31f6935223ec269ad1539350444ec7b39770a
Author: Beau <cbeauhilton@gmail.com>
Date:   Wed, 10 Nov 2021 11:31:42 -0600

mr sunthankar

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learn/2021-11-10-mr-sunthankar.md
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+# Morning Report
+
+Katie Sunthankar, MD
+
+# case
+
+CC: Fever
+
+HPI: 
+~30F, 
+2d general body aches,
+TMax 103.8, 
+nausea, 
+diffuse abd pain and HA.
+Unresponsive to APAP.
+NBNB emesis -> presentation VUMC ED.
+UTI x2, 4 and 2 wk PTA, tx w macrobid and bactrim.
+UTI sx never truly resolved.
+Recently returned from glamping trip in the MidWest,
+3wk prior to now.
+
+PMHx/PSHx: none
+Meds: OCPs
+FHx: Dad w afib, sis w eczema/scoliosis, PGF leukemia
+SHx: from northern Europe (here for >10y), 
+1ppd x2y, 
+no pets, 
+little EtOH, 
+works in an office setting
+
+Exam:
+100.9F, HR 149, BP 120/70, on RA
+HEENT: mildly red tonsils, tender anterior cervical LA
+Abd: suprapubic tenderness
+Skin: no rashes
+
+Labs:
+Na 133, WBC 1.1, Hgb 13.2, plt 233 (CBC 6-7mo prior totally wnl)
+ANC 0.0, ALC 920, 3% atypical lymphs, no blasts
+LFTs fine.
+UA: +ketones, +bili (no urobilinogen), >500 protein
+UPC: 0.2 grams/day
+CRP: 252
+Huge infx (tickborne, viral, urine/serum fungal), w/u -ve.
+
+## Dx: 
+Agranulocytosis d/t bactrim
+
+### Agranulocytosis
+
+ANC <200.
+
+Inherited: BEN, familial neutropenia, congenital neutropenia
+
+Infx: HIV, EBV, CMV, HHV6, measles, rubella, varicella, brucella, tularemia, TB, shigella, anaplasmosis, 
+
+Drugs: 
+- weeks-months after initiation of drug, typically ~4wks, 2-15 cases/y/10^6 people, mean age 51, M==F
+- anti-thyroid (PTU, _MMI_), psych: _clozapine_ (MCC), antibacterial (_bactrim_, macrolides, cephalo, dapsone, penicillin), NSAIDs, colchicine, _sulfasalazine_
+
+MoA drug-induced: not clear, two hypotheses (good review in Blood)
+- hapten (covalent binding to cell surface protein by reactive metabolites)
+- danger signal (+inflammasome by drug-protein conjugates w/in PMN, +oxidized)
+- some GWAS studies underway, may have association w HLA
+
+Duration - mean 8d, but can be much longer
+
+Presentation - ~50% present w infx
+
+BMBx - usually hypoplastic, but could be hyperplastic or have other goofiness
+
+Outcomes - possibly improved over the years. No significant difference wwo GCSF, however most folks do get GCSF.
+
+Some learning points:
+- acute toxo can look exactly like mono, down to splenomegaly
+- no one should die w/o a dose of doxy
+- don't mix azathioprine w allopurinol