Medical Mystery Solved - A Treacherous Course | NEJM

This Double Take video from the New England Journal of Medicine presents the
case of a man with acute onset of nausea, vomiting, abdominal pain, fever, and
hemoptysis. Based on a Clinical Problem-Solving article published in the Journal,
the video explores the differential diagnosis based on the patient’s presenting
symptoms and follows the evolution of the diagnosis as new findings arise from
the diagnostic evaluation and the patient’s clinical course. For further reading,
the article mentioned above, referenced in the video, is available at www.nejm.org/d... : A
Treacherous Course (Jilg et al., in the March 4, 2021, issue of the Journal).
The New England Journal of Medicine is the world’s leading general medical
journal. Continuously published for over 200 years, the Journal publishes
peer-reviewed research along with interactive clinical content for physicians,
educators, and the global medical community at NEJM.org.

[@malexander2438]

Great video and good holistic care message underlying this interesting case. Thank you

[@Abdullah_DS]

Love this kind of videos.. Does anyone any channel provide this kind of videos?

[@badassnewbie]

idk, I'm gonna put this one on the family. They didn't think it was important to mention this guy swam through a large river and then hiked his way through the entire southern US before suddenly falling ill shortly afterwards?

[@dennisachionye]

This is amazing

[@LittlePurpleBook]

amazing.

[@ferchosando5207]

Amazing

[@kumaradarsh3983]

Why did he continue to deteriorate even after doxy administration?

[@ooaaveehoo]

I would guess it's because doxycycline is bacteriostatic (doesn't kill bacteria, just stops them from reproducing) so it it will take a bit more time for the disease to start getting better and the damage and the disease can still progress while the bactrial load doesn't go up.

[@alexsandraskvortcova]

Thank you. +103 Sasha

[@wowhimin]

Disagree. Clinical history was never important in this case. You must consider leptospirosis/HPS in the situations like this (acute onset, rapid progression, fever + ARDS/DAD + liver failure + renal failure), even if you don't have enough information about the patient's personal life. And I believe that is the primary reason why they started doxy. Lab confirmation always takes some time. That dramatic clinically history probably was just a coincidence. Although clinical history does matter in many cases, its importance is too much exaggerated in this video.

[@SireCs133]

Why do you think he deteriorated even while on doxycycline?

[@wowhimin]

​@@SireCs133 You have to consider how antibiotics work. Many antibiotics work by blocking replication of bacteria. Antibiotics don't 'kill' bacteria themselves. They just block replication, and immune cells kill bacteria and clean up bacterial proteins. On the other hand, symptoms of bacterial infection are mostly due to inflammatory processes. It takes time to see clinical improvement after initiating antibiotics, even the appropriate ones.

[@faresasfary]

Med student here Question If I have multiple micros that can cause similar symptoms, how does one differentiate between them especially when the patient's health is deteriorating rapidly?

[@Hongard_Golf_TV]

@@faresasfary Consultant pathologist here. To identify pathogens, you can try microbiological (bacterial culture or MALDI-TOF), serological (antigen/antibody), or molecular (PCR) detection methods. Whether to perform them all together or stage by stage depends on how severe and urgent the patient's condition is.

[@wowhimin]

​​@@faresasfary Good question. The thing is, you don't really have to know what pathogen is causing the illness at that situation. What you have to know is the probabilities of possible pathogens in specific situations. All you have to do is to select the appropriate broad spectrum antibiotics that covers the most of the frequent pathogens. It's all because microbial confirmation takes time. After you identify the specific pathogen and its antibiotic susceptibility, then you decide to switch the antibiotics accordingly. That's the basic concept of empiric antimicrobial treatment.

[@ultra2187]

Isn't vanco and pip-tazo incompatible?

[@itsmevd9916]

Haha how important is the epidemiology. Im from india and we never miss lepto. 1st DD for DAD/ ARDS in a male in south india is infections esp lepto,scrub. Lepto will cause more of cholestasis rather than jaundice and transaminitis. Eg Br will be 2.5,ot pt will be 150 like that, alp will be 360 like that. A single lft can clinch the diagnosis. Indians work in resource poor settings and so they have mastered basic investigations. We never do panels like u do unless for rare diseases.

[@Fomites]

Too many acronyms.

[@itsmevd9916]

@@Fomites Medicos can understand my comment bro.