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February 18, 2014 Issue

Clinical Practice Points


Medical Knowledge
Patient Care
Interpersonal and Communication Skills
Professionalism

Microsporidiosis Acquired Through Solid Organ Transplantation. A Public Health Investigation

This study evaluates a cluster of Encephalitozoon cuniculi infections in 3 solid organ transplant recipients, who are linked to a single donor. This microsporidial species is most commonly recognized as a cause of renal, respiratory, and central nervous system infections in immunosuppressed patients. The authors suggest adding microsporidiosis to the differential diagnosis in febrile transplant recipients.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the appropriate work-up of fever in transplant recipients.
  • Review with your learners the infections for which solid organ transplant recipients are at risk, and when.
  • Review the typical microbiology of microsporidiosis infection.
  • Discuss with your learners whether they would include this type of infection in the informed consent surrounding a transplant. What components of risk must be included in proper informed consent? Does every possible adverse outcome need to be named?

Patient Care
Medical Knowledge
High Value Care

Cost-Effectiveness of Genotype-Guided and Drug-Only Dual Antiplatelet Therapies in Acute Coronary Syndrome

This study assesses the cost-effectiveness of 5 strategies for selecting antiplatelet drugs after acute coronary syndrome, recognizing that there may be genotypic variation in patients’ responses to clopidogrel.

Use this study to:

  • Review antiplatelet recommendations for acute coronary syndrome.
  • Invite an expert in cost-effectiveness analysis to review with your team how to read such studies. To whom are they helpful? What are quality-adjusted life-years and incremental cost-effectiveness ratios? What are the assumptions that one needs to consider carefully in evaluating such a study? You can also use a short primer to help you review these topics with your learners.

Clinical Practice Guidelines


Practice Based Learning and Improvement
Patient Care
Interpersonal and Communication Skills
Professionalism
Medical Knowledge

Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation

Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement

The U.S. Preventive Services Task Force recommends screening women who have family members with breast, ovarian, tubal, or peritoneal cancer to identify a family history that may be associated with an increased risk for mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Routine genetic counseling or BRCA testing for women whose family history is not associated with an increased risk for mutations in the BRCA1 or BRCA2 genes is not recommended.

Use these papers to:

  • Review the recommendations with patients who are at increased risk for breast cancer. How do screening recommendations differ according to risk?
  • Ask your learners what they know about BRCA and how mutations are thought to increase risk.
  • Ask how the guideline developers used the results of the systematic review to inform their recommendations. What are the strengths of this approach? What are the weaknesses?
  • Review other current guidelines for breast cancer screening, such as those from the American Cancer Society and American College of Obstetricians and Gynecologists. How do they differ, and why? What will your learners advise for their patients?
  • Ask your learners how they will answer questions about prophylactic mastectomy. Have any of them been asked about this after a celebrity had this procedure? Show your learners the Summary for Patients that can help explain the guideline's recommendations. Use a recent research study to discuss what patients perceive and understand about breast cancer risk and prophylactic mastectomy—as well as the summary for patients to this article.

Humanism and Professionalism


Professionalism

On Being a Doctor Again

In this essay, Dr. Liu discusses her recovery from a devastating brain injury and her search for new ways to use her skills.

Use this essay to:

  • Play an audio recording of this piece.
  • Have your learners reflect on what drew them into medicine as a career. If they were injured and could no longer practice, what would they miss the most? Use this as an opportunity to discuss burnout, empathy, and preserving humanism.

Video Learning

The Consult Guys logo

The Consult Guys — What Does Aortic Stenosis Have to Do With Heme-Positive Stool?

Learn and laugh with your team while you watch this episode of the Consult Guys. Be sure to answer the multiple-choice questions as a fun way to review with your team—and complete the answers online to get free CME credit for yourself!



mksap16

A 44-year-old woman is evaluated for a 1-week history of low-grade fever, fatigue, and body aches. She had a kidney transplant 5 months ago; at the time of transplantation, she was seropositive for Epstein-Barr virus and seronegative for cytomegalovirus with a seropositive donor. Her recent course has been uncomplicated with no episodes of rejection. She completed cytomegalovirus prophylaxis with valganciclovir last month. Medications are tacrolimus, mycophenolate mofetil, prednisone, and trimethoprim-sulfamethoxazole.

On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 136/88 mm Hg, pulse rate is 96/min, and respiration rate is 16/min. There is no lymphadenopathy. The transplant surgical wound site is without erythema or drainage. Cardiopulmonary examination is normal. The abdomen is soft and nontender.

Laboratory studies:

Hematocrit 33%
Leukocyte count 3200/μL (3.2 × 109/L)
Platelet count 112,000/μL (112 × 109/L)
Alkaline phosphatase 155 units/L
Alanine aminotransferase 52 units/L
Aspartate aminotransferase 48 units/L
Bilirubin 0.6 mg/dL (10.3 μmol/L)
Blood urea nitrogen 18 mg/dL (6.4 mmol/L)
Creatinine 1.1 mg/dL (97.2 μmol/L)

Microscopic urinalysis is unremarkable. The chest radiograph is normal.

Infection with which of the following is the most likely diagnosis?

A. Cytomegalovirus
B. Epstein-Barr virus
C. Listeria monocytogenes
D. Polyoma BK virus

Correct Answer:
A. Cytomegalovirus

Key Point
Cytomegalovirus infection typically occurs in the first few months after solid organ transplantation (the middle period); is characterized by fever, malaise, leukopenia, and thrombocytopenia; and may involve the lungs or gastrointestinal tract.

Educational Objective
Diagnose cytomegalovirus infection after kidney transplantation.

This patient has cytomegalovirus (CMV) infection and disease presenting as the CMV syndrome, which typically occurs in the first few months after transplantation. Typical findings include fever, cytopenias, and hepatitis and may include pneumonitis or colitis. The onset of CMV in this patient was delayed by the prophylaxis given for the first few months following transplantation. The periods following solid organ transplant during which opportunistic infections can occur are the early period (within the first month after transplantation), the middle period (the first few months after transplantation), and the late period (more than a few months after transplantation). This patient is at higher risk for CMV infection because she was a seronegative recipient of an organ from a seropositive donor. Testing for CMV viremia should be performed, and treatment with intravenous ganciclovir or oral valganciclovir should be started.

This patient is also at risk for Epstein-Barr virus reactivation and disease, and this would be the appropriate time frame (5 months posttransplantation) for this infection to occur; however, in transplant recipients, this infection usually presents with lymphadenopathy as Epstein-Barr virus–associated posttransplant lymphoproliferative disease. Lymphadenopathy is absent in this patient.

Listeria monocytogenesinfection may occur during this posttransplantation time frame but more often causes meningoencephalitis with headache and mental status changes or neurologic deficits, which this patient does not have.

Polyoma BK virus infection is a late complication of transplantation. Kidney transplant recipients with BK virus infection may develop BK-related nephropathy, organ rejection, or ureteral strictures. Transplant recipients with BK-related nephropathy have decoy cells in the urine (cells with intranuclear inclusions), evidence of which is absent in this patient.

Bibliography
De Keyzer K, Van Laecke S, Peeters P, Vanholder R. Human cytomegalovirus and kidney transplantation: a clinician's update. Am J Kidney Dis. 2011;58(1):118-126. PMID: 21684438

These questions were derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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