1 00:00:17,655 --> 00:00:19,894 Hey, everybody. Thanks for tuning in to Palm 2 00:00:19,894 --> 00:00:22,454 Peeps. We are very excited today to be 3 00:00:22,454 --> 00:00:24,775 joining you with another episode. We haven't done 4 00:00:24,775 --> 00:00:26,054 one of these in a little while. We're 5 00:00:26,054 --> 00:00:27,035 getting a preliminary 6 00:00:27,414 --> 00:00:29,414 fellows case file today. These are one of 7 00:00:29,414 --> 00:00:30,074 our favorite 8 00:00:30,420 --> 00:00:32,659 episode types that Monty and I get to 9 00:00:32,659 --> 00:00:34,979 record and meet fellows and program directors from 10 00:00:34,979 --> 00:00:36,899 across the country. So we're very excited to 11 00:00:36,899 --> 00:00:38,500 be back with you and take you through 12 00:00:38,500 --> 00:00:40,500 a really interesting case. But before we do 13 00:00:40,500 --> 00:00:42,340 that, as always, join with my partner in 14 00:00:42,340 --> 00:00:45,079 crime, Christina Montanor. Christina, how's it going? 15 00:00:45,965 --> 00:00:48,524 Hey, Ferb. Good morning. Doing great. Glad to 16 00:00:48,524 --> 00:00:50,604 be back with you. I feel, like, haven't 17 00:00:50,604 --> 00:00:52,125 seen you in a few weeks, so this 18 00:00:52,125 --> 00:00:53,884 is always the best part of my week. 19 00:00:53,884 --> 00:00:55,564 So excited to be back. And as you 20 00:00:55,564 --> 00:00:57,899 said with another Fellow's case files, I feel 21 00:00:57,899 --> 00:01:00,460 like we've had some new initiatives for 2025 22 00:01:00,460 --> 00:01:02,879 including our guideline series, which have been fantastic. 23 00:01:03,339 --> 00:01:05,420 But the Fellow's case files remain one of 24 00:01:05,420 --> 00:01:07,420 my favorite episodes that we do because we 25 00:01:07,420 --> 00:01:09,439 get to hear from fantastic 26 00:01:09,819 --> 00:01:12,799 educators, trainees from across the country. So 27 00:01:13,105 --> 00:01:15,984 really excited today to be virtually visiting Rutgers 28 00:01:15,984 --> 00:01:18,784 University and Robert Wood Johnson Medical School, which 29 00:01:18,784 --> 00:01:20,864 I have not visited personally, but I still 30 00:01:20,864 --> 00:01:22,625 think for if we're gonna go on a 31 00:01:22,625 --> 00:01:24,944 summer road trip in a bus and Yeah. 32 00:01:25,025 --> 00:01:27,000 Visit all the Fellowes case files that we've 33 00:01:27,000 --> 00:01:28,920 done. So I still think we're gonna make 34 00:01:28,920 --> 00:01:31,659 that happen. A %. A bus or Winnebago, 35 00:01:31,799 --> 00:01:33,159 we'll have to we'll have to decide on 36 00:01:33,159 --> 00:01:35,259 the best mode of transport for us. 37 00:01:35,879 --> 00:01:36,379 Exactly. 38 00:01:36,920 --> 00:01:38,840 But really excited to get started today, and 39 00:01:38,840 --> 00:01:40,194 we have two guests today, and I have 40 00:01:40,194 --> 00:01:42,515 the honor of introducing our first guest. We 41 00:01:42,515 --> 00:01:44,055 have doctor Khalil Elgarib. 42 00:01:44,435 --> 00:01:47,155 Khalil completed his residency training at Northwell at 43 00:01:47,155 --> 00:01:50,275 Staten Island University Hospital program and is currently 44 00:01:50,275 --> 00:01:52,275 a first year fellow at Rutgers Robert Wood 45 00:01:52,275 --> 00:01:54,899 Johnson Medical School. And Khalil reached out to 46 00:01:54,899 --> 00:01:56,899 us with a fantastic case that I'm really 47 00:01:56,899 --> 00:01:59,219 excited for us to go through today and 48 00:01:59,219 --> 00:02:00,420 such an honor to have you on the 49 00:02:00,420 --> 00:02:02,519 show today. Welcome to Palm Peeps, Khalil. 50 00:02:03,379 --> 00:02:06,179 Thank you for the introduction, Christina. I'm a 51 00:02:06,179 --> 00:02:08,659 big fan of the show and I'm thrilled 52 00:02:08,659 --> 00:02:09,400 to be here. 53 00:02:09,805 --> 00:02:11,405 Yeah. Thank you. We're thrilled to have you, 54 00:02:11,405 --> 00:02:13,104 and thanks for listening, certainly. 55 00:02:13,485 --> 00:02:16,205 Next, we have doctor Sabia Hussain. Sabia completed 56 00:02:16,205 --> 00:02:18,525 her residency training at Robert Wood Johnson Medical 57 00:02:18,525 --> 00:02:20,525 School and her fellowship training in pulmonary and 58 00:02:20,525 --> 00:02:23,110 critical care at Columbia Presbyterian Medical Center in 59 00:02:23,110 --> 00:02:25,110 New York, where I did my fellowship. So 60 00:02:25,110 --> 00:02:27,349 we're bonded for life by that. She is 61 00:02:27,349 --> 00:02:29,750 currently a professor of medicine, and the program 62 00:02:29,750 --> 00:02:32,469 director for the pulmonary critical care medicine fellowship 63 00:02:32,469 --> 00:02:34,409 program. Thanks for coming on the show. 64 00:02:34,789 --> 00:02:36,870 Oh, thanks so much for having me. I'm 65 00:02:36,870 --> 00:02:37,689 really excited. 66 00:02:39,185 --> 00:02:41,504 Wonderful. Excited to have you and walk through 67 00:02:41,504 --> 00:02:44,245 some really great teaching points with us today. 68 00:02:44,465 --> 00:02:46,544 As our quick disclaimer, just a reminder, the 69 00:02:46,544 --> 00:02:48,064 podcast is not meant to be used for 70 00:02:48,064 --> 00:02:50,064 medical advice, and the views we expressed today 71 00:02:50,064 --> 00:02:52,349 do not reflect the opinions or policies of 72 00:02:52,349 --> 00:02:53,569 our respective employers. 73 00:02:53,949 --> 00:02:56,349 The case we'll present today is HIPAA compliant, 74 00:02:56,349 --> 00:02:58,030 and some details might have been changed to 75 00:02:58,030 --> 00:02:59,729 protect the privacy of our patient. 76 00:03:00,750 --> 00:03:02,430 But let's go ahead and dive into the 77 00:03:02,430 --> 00:03:04,750 case. Khalil, you as I said, you this 78 00:03:04,750 --> 00:03:06,050 was your brainstorming 79 00:03:06,590 --> 00:03:07,810 and great 80 00:03:08,325 --> 00:03:10,405 educational feature that you wanted to share on 81 00:03:10,405 --> 00:03:12,325 the show today. So why don't you go 82 00:03:12,325 --> 00:03:13,764 ahead and tell us about the patient that 83 00:03:13,764 --> 00:03:15,465 you met and how they initially presented? 84 00:03:16,564 --> 00:03:18,645 This is a patient that we met a 85 00:03:18,645 --> 00:03:20,889 couple of years ago in the clinic. It's 86 00:03:20,889 --> 00:03:22,650 a 28 year old male patient with a 87 00:03:22,650 --> 00:03:25,610 past medical history of Asperger's syndrome and IgA 88 00:03:25,610 --> 00:03:26,110 nephropathy 89 00:03:26,490 --> 00:03:28,969 who presents to the emergency department for shortness 90 00:03:28,969 --> 00:03:31,930 of breath and cough. The caregiver reports that 91 00:03:31,930 --> 00:03:33,930 the patient has been having dry cough and 92 00:03:33,930 --> 00:03:34,990 dyspnea ambulation, 93 00:03:35,625 --> 00:03:37,705 progressing for the past three months prior to 94 00:03:37,705 --> 00:03:39,245 the presentation to the ED. 95 00:03:39,704 --> 00:03:41,704 The patient didn't have any wheezing, no chest 96 00:03:41,704 --> 00:03:44,604 pain, no palpitations, or any constitutional symptoms. 97 00:03:44,985 --> 00:03:48,125 The patient's medications were van stropin and oxcarbazepine, 98 00:03:49,040 --> 00:03:52,080 and his social history is mainly notable for 99 00:03:52,080 --> 00:03:52,580 questionable 100 00:03:53,040 --> 00:03:55,840 black mold exposure in the apartment where he 101 00:03:55,840 --> 00:03:56,340 resides. 102 00:03:58,879 --> 00:04:01,040 Great. So thanks so much for sharing that, 103 00:04:01,040 --> 00:04:04,495 Felil. And I say fairly common pulmonary visit, 104 00:04:04,495 --> 00:04:06,895 at least from a complaint standpoint and chief 105 00:04:06,895 --> 00:04:09,854 complaint that we're hearing, although in a much 106 00:04:09,854 --> 00:04:12,014 typically younger patient than we probably see on 107 00:04:12,014 --> 00:04:12,514 average. 108 00:04:13,534 --> 00:04:15,055 So, Dave, I would love for you to 109 00:04:15,055 --> 00:04:17,794 share how you'd start your diagnostic reasoning approach 110 00:04:17,819 --> 00:04:19,040 for the specific patient. 111 00:04:20,060 --> 00:04:22,540 Yeah. Absolutely. This is something we've talked about 112 00:04:22,540 --> 00:04:25,279 a lot on the show about critical thinking 113 00:04:25,500 --> 00:04:28,060 and diagnostic reasoning. I think we 114 00:04:28,460 --> 00:04:29,439 everybody uses 115 00:04:29,740 --> 00:04:32,220 variety of modalities to think about a new 116 00:04:32,220 --> 00:04:34,985 patient, and it's important to have some metacognition 117 00:04:35,365 --> 00:04:37,144 about that. And so I think the common 118 00:04:37,285 --> 00:04:39,685 ones that people use are diagnostic schemas and 119 00:04:39,685 --> 00:04:42,084 illness scripts. You hear about some symptoms. You're 120 00:04:42,084 --> 00:04:44,245 trying to fit them into a pattern that 121 00:04:44,245 --> 00:04:45,064 you recognize, 122 00:04:45,444 --> 00:04:47,285 and then you're trying to go down based 123 00:04:47,285 --> 00:04:48,264 on different likelihoods, 124 00:04:48,649 --> 00:04:50,750 different parts of that sort of flow diagram. 125 00:04:51,050 --> 00:04:53,290 And thinking about that consciously is that sort 126 00:04:53,290 --> 00:04:55,930 of type two slow thinking. We do it 127 00:04:55,930 --> 00:04:58,410 very unconsciously while we're gathering information in the 128 00:04:58,410 --> 00:05:00,730 clinic, that sort of type one rapid reasoning 129 00:05:00,730 --> 00:05:01,230 response. 130 00:05:01,634 --> 00:05:03,314 And this is a very common complaint. As 131 00:05:03,314 --> 00:05:04,754 you said, we're thinking about a patient who's 132 00:05:04,754 --> 00:05:07,235 coming in with cough, and then we wanna 133 00:05:07,235 --> 00:05:08,454 amend just that 134 00:05:08,834 --> 00:05:09,654 basic presentation 135 00:05:10,034 --> 00:05:13,095 with some info that will change the likelihoods 136 00:05:13,235 --> 00:05:15,389 of diagnosis. So those have to do with 137 00:05:15,389 --> 00:05:17,569 the chief complaint, the substrate, predisposing 138 00:05:17,870 --> 00:05:20,189 conditions, and exposures. As you said, this is 139 00:05:20,189 --> 00:05:22,270 a relatively younger patient. We don't have any 140 00:05:22,270 --> 00:05:24,189 history of smoking or things like that lead 141 00:05:24,189 --> 00:05:26,270 us down a different pathway, and we're thinking 142 00:05:26,270 --> 00:05:26,770 about 143 00:05:27,150 --> 00:05:30,449 what sounds like a progressive chronic dry cough. 144 00:05:30,544 --> 00:05:31,985 And so if we were thinking about that, 145 00:05:31,985 --> 00:05:33,985 the most common reasons for that in The 146 00:05:33,985 --> 00:05:36,324 United States are GERD, postnasal 147 00:05:36,625 --> 00:05:39,685 drip, cough variant asthma. There's actually an excellent 148 00:05:39,824 --> 00:05:41,425 review article that just came out in the 149 00:05:41,425 --> 00:05:44,020 New England Journal on chronic refractory cough. It 150 00:05:44,020 --> 00:05:46,100 was a really great read and definitely good 151 00:05:46,100 --> 00:05:48,740 for any pulmonary provider or fellow to read 152 00:05:48,740 --> 00:05:49,240 about. 153 00:05:49,540 --> 00:05:51,540 But I think the key thing that helps 154 00:05:51,540 --> 00:05:54,020 me distinguish how I'm gonna approach this patient 155 00:05:54,020 --> 00:05:55,964 is that he's also having dyspnea on exertion. 156 00:05:56,044 --> 00:05:58,144 Exertion. And so cough in isolation 157 00:05:58,524 --> 00:05:59,904 and a dry cough in isolation 158 00:06:00,365 --> 00:06:02,925 is very different than a cough with dyspnea 159 00:06:02,925 --> 00:06:04,764 on exertion because now I'm starting to think 160 00:06:04,764 --> 00:06:06,865 a little bit more about the lung parenchyma, 161 00:06:07,245 --> 00:06:10,029 about airways disease that's reaching a level that's 162 00:06:10,029 --> 00:06:12,910 affecting the patient's ability to exert themselves. I'm 163 00:06:12,910 --> 00:06:15,230 starting to really think about if that cough 164 00:06:15,230 --> 00:06:15,970 is reflecting 165 00:06:16,270 --> 00:06:18,370 some more progressive pulmonary process. 166 00:06:18,750 --> 00:06:20,430 And then one thing of interest that the 167 00:06:20,430 --> 00:06:22,210 patient brought up, and this is not uncommon, 168 00:06:22,270 --> 00:06:24,110 is that they talked about a possible exposure 169 00:06:24,110 --> 00:06:26,084 to mold. And so I think mold is 170 00:06:26,084 --> 00:06:29,365 a broad bucket term, hot term for most 171 00:06:29,365 --> 00:06:31,204 people, like in the public. And so you'll 172 00:06:31,204 --> 00:06:32,724 often get a patient that comes up and 173 00:06:32,724 --> 00:06:34,404 says, I was told I have mold or 174 00:06:34,404 --> 00:06:36,324 there's mold in the workplace, and they're a 175 00:06:36,324 --> 00:06:38,084 little bit worried about that. And it certainly 176 00:06:38,084 --> 00:06:40,600 should affect our thinking some. So, Sabi, I 177 00:06:40,600 --> 00:06:42,279 was wondering if you could tell us how 178 00:06:42,279 --> 00:06:45,079 you think about your diagnostic reasoning and what 179 00:06:45,079 --> 00:06:46,919 changes about it when a patient mentions a 180 00:06:46,919 --> 00:06:47,740 mold exposure. 181 00:06:49,240 --> 00:06:51,639 Yeah. Thanks so much, Dave. Yeah. I think 182 00:06:51,639 --> 00:06:53,560 that there's a lot of things that when 183 00:06:53,560 --> 00:06:55,604 you have a patient that comes in that's 184 00:06:55,604 --> 00:06:56,504 having progressive 185 00:06:56,964 --> 00:06:58,104 symptoms and dyspnea, 186 00:06:58,564 --> 00:07:00,884 especially as you were saying, this younger age 187 00:07:00,884 --> 00:07:03,125 population, you really do have to think about, 188 00:07:03,125 --> 00:07:04,024 like, exposure. 189 00:07:04,564 --> 00:07:06,805 And and so this individual tells you a 190 00:07:06,805 --> 00:07:09,044 little bit about mold and mold exposure. So 191 00:07:09,044 --> 00:07:09,810 that's like 192 00:07:10,290 --> 00:07:12,850 puts your thinking caps on and figuring out, 193 00:07:12,850 --> 00:07:15,169 like, what does this mean? And as mold 194 00:07:15,169 --> 00:07:17,750 is, like, all around us, it's ubiquitous. It's 195 00:07:17,810 --> 00:07:19,910 in the indoor and the outdoor environment. 196 00:07:20,370 --> 00:07:23,110 And in majority of cases, most humans 197 00:07:23,895 --> 00:07:26,694 and and mold coexist. Like, they don't have 198 00:07:26,694 --> 00:07:28,154 any issues or problems 199 00:07:28,535 --> 00:07:30,935 that are going on. But then there are 200 00:07:30,935 --> 00:07:31,435 individuals 201 00:07:31,895 --> 00:07:34,694 that this mold could then re lead to 202 00:07:34,694 --> 00:07:36,634 other things like allergic rhinitis, 203 00:07:37,095 --> 00:07:37,595 complications 204 00:07:37,895 --> 00:07:38,634 of allergic 205 00:07:39,080 --> 00:07:42,839 asthma. And then less frequently, these moles can 206 00:07:42,839 --> 00:07:44,779 result in atopic conditions 207 00:07:45,080 --> 00:07:46,860 such as allergic bronchopulmonary, 208 00:07:47,960 --> 00:07:48,460 astragelosis, 209 00:07:49,080 --> 00:07:50,460 and allergic fungal 210 00:07:50,839 --> 00:07:51,339 rhinosinusitis. 211 00:07:52,665 --> 00:07:56,024 Rarely do they present as, maybe in this 212 00:07:56,024 --> 00:07:56,524 instance, 213 00:07:56,985 --> 00:07:57,805 as hypersensitivity 214 00:07:58,264 --> 00:08:00,764 pneumonitis, and that really would be something that's 215 00:08:00,824 --> 00:08:03,404 high semi differential right now in this individual. 216 00:08:03,944 --> 00:08:05,060 And so 217 00:08:05,439 --> 00:08:08,720 you think about, like, exposures. So sometimes, like, 218 00:08:08,720 --> 00:08:09,220 occupational 219 00:08:09,600 --> 00:08:13,620 exposure that can cause these kinds of hypersensitivity 220 00:08:14,240 --> 00:08:15,620 and pneumonitis symptoms. 221 00:08:16,240 --> 00:08:17,860 And so we do 222 00:08:18,205 --> 00:08:20,225 try to figure out exactly 223 00:08:21,004 --> 00:08:23,965 how much exposure that individual is happening is 224 00:08:23,965 --> 00:08:24,465 having. 225 00:08:24,925 --> 00:08:26,305 Is that exposure 226 00:08:26,764 --> 00:08:27,264 continuing? 227 00:08:27,965 --> 00:08:30,810 And all those kinds of things does go 228 00:08:30,810 --> 00:08:31,310 into, 229 00:08:31,849 --> 00:08:34,750 will we take this mold exposure seriously? 230 00:08:36,889 --> 00:08:38,570 That's really great. Hey. I think you bring 231 00:08:38,570 --> 00:08:40,490 up some great points so that we have 232 00:08:40,490 --> 00:08:41,769 to think about this. It puts it at 233 00:08:41,769 --> 00:08:44,095 the forefront of our mind. That being said, 234 00:08:44,095 --> 00:08:47,315 most of the time, these things are mild 235 00:08:47,375 --> 00:08:49,454 exposures, and there might be something else going 236 00:08:49,454 --> 00:08:50,894 on, so we don't just hone in on 237 00:08:50,894 --> 00:08:52,735 that. And then I think you also hit 238 00:08:52,735 --> 00:08:54,434 the nail ahead of figuring out 239 00:08:54,815 --> 00:08:58,259 how significant and real and continuous this exposure 240 00:08:58,259 --> 00:08:59,940 is. Is this something the person can get 241 00:08:59,940 --> 00:09:01,620 away from? And there are a variety of 242 00:09:01,620 --> 00:09:03,940 different ways to do that, including having somebody 243 00:09:03,940 --> 00:09:05,700 even go out to a patient's work or 244 00:09:05,700 --> 00:09:08,019 home to try to understand what's going on. 245 00:09:08,019 --> 00:09:09,220 So these are things we'll have in the 246 00:09:09,220 --> 00:09:10,420 back of our head as we continue to 247 00:09:10,420 --> 00:09:12,544 hear more about the patient. So, Kahlil, can 248 00:09:12,544 --> 00:09:14,144 you move us forward in case? Tell us 249 00:09:14,144 --> 00:09:16,004 a little bit about the patient's exam. 250 00:09:16,785 --> 00:09:18,884 Sure. In the EDE, the patient was hemodynamically 251 00:09:19,345 --> 00:09:22,884 stable, but his pulse ox was around 91% 252 00:09:22,945 --> 00:09:23,924 on room air. 253 00:09:24,309 --> 00:09:27,269 His, examination was mainly notable for crackles in 254 00:09:27,269 --> 00:09:29,269 the right upper and lower lung fields as 255 00:09:29,269 --> 00:09:31,290 well as in the left upper lung fields. 256 00:09:31,750 --> 00:09:33,830 So, Christina, can you tell us how this 257 00:09:33,830 --> 00:09:35,690 exam would influence your thinking? 258 00:09:37,245 --> 00:09:39,725 Sure. Thanks so much, Khalil. I think here, 259 00:09:39,725 --> 00:09:41,485 it's really important, the pulse ox that you 260 00:09:41,485 --> 00:09:43,485 mentioned as well as the physical exam findings. 261 00:09:43,485 --> 00:09:44,925 So I'd like to go ahead and first 262 00:09:44,925 --> 00:09:47,565 talk about the ninety one percent on room 263 00:09:47,565 --> 00:09:49,965 air. Right? This is atypical for a 28 264 00:09:49,965 --> 00:09:52,029 year old at rest, Something that I would 265 00:09:52,029 --> 00:09:54,750 consider to be abnormal and would really probably 266 00:09:54,750 --> 00:09:56,909 have our head head scratching. Something's going on 267 00:09:56,909 --> 00:09:58,829 here. I think we'll definitely wanna get a 268 00:09:58,829 --> 00:10:00,990 gas, and this would be a patient who's 269 00:10:01,230 --> 00:10:01,730 has, 270 00:10:02,589 --> 00:10:04,769 be I would be concerned about having exertional 271 00:10:04,829 --> 00:10:05,329 hypoxemia. 272 00:10:05,995 --> 00:10:07,514 So if we were able to get an 273 00:10:07,514 --> 00:10:09,195 ambulatory sat on him, this would be a 274 00:10:09,195 --> 00:10:11,514 patient that I would definitely consider that in. 275 00:10:11,514 --> 00:10:13,295 But really starting to think about 276 00:10:13,835 --> 00:10:16,795 with this 91% on room air honing in 277 00:10:16,795 --> 00:10:19,054 on the diagnosis and the etiologies of hypoxemia. 278 00:10:19,835 --> 00:10:20,955 So I think with that 279 00:10:21,620 --> 00:10:23,459 adding to that are is a physical exam 280 00:10:23,459 --> 00:10:25,799 finding. So you said there's crackles scattered throughout. 281 00:10:26,179 --> 00:10:28,579 And while we say sometimes you can say 282 00:10:28,579 --> 00:10:31,620 dry versus wet crackles, the physical exam, I 283 00:10:31,620 --> 00:10:34,440 think, is somewhat not the best at distinguishing 284 00:10:34,500 --> 00:10:35,720 between those two etiologies. 285 00:10:36,485 --> 00:10:38,485 Well, I think using our exam, knowing an 286 00:10:38,485 --> 00:10:38,985 abnormality, 287 00:10:39,365 --> 00:10:41,445 trying to figure out what diagnostic test would 288 00:10:41,445 --> 00:10:43,464 be appropriate to order and what we anticipate 289 00:10:43,605 --> 00:10:46,004 to show on that diagnostic test. But I 290 00:10:46,004 --> 00:10:47,605 think when we're really saying, like, we we 291 00:10:47,605 --> 00:10:49,840 feel like we hear a wet crackle, I 292 00:10:49,840 --> 00:10:51,279 tend to correlate that with more of an 293 00:10:51,279 --> 00:10:52,659 alveolar filling process, 294 00:10:53,120 --> 00:10:55,779 whereas I hear, like, dry or fine crackles 295 00:10:55,840 --> 00:10:57,139 or even, like, the Velcro 296 00:10:57,600 --> 00:11:00,179 crackles, sometimes that's commonly used for terminology, 297 00:11:00,559 --> 00:11:02,659 I would correlate that more with a pringable 298 00:11:02,720 --> 00:11:03,220 process. 299 00:11:03,884 --> 00:11:06,205 So I think either one is definitely concerning 300 00:11:06,205 --> 00:11:07,965 in this patient and lines up with the 301 00:11:07,965 --> 00:11:10,684 relative hypoxemia that we're seeing. And I think 302 00:11:10,684 --> 00:11:12,205 to think about because you think as we're 303 00:11:12,205 --> 00:11:14,545 seeing someone very early on in the course, 304 00:11:14,684 --> 00:11:16,125 there's gonna be a lot of tests that 305 00:11:16,125 --> 00:11:18,205 are ordered, but this is a patient, and 306 00:11:18,205 --> 00:11:20,330 when I work with trainees, would really like 307 00:11:20,330 --> 00:11:22,570 to say, based off our physical exam and 308 00:11:22,570 --> 00:11:25,050 based off the current diagnostic testing that we 309 00:11:25,050 --> 00:11:27,290 have, like, what do we anticipate we're going 310 00:11:27,290 --> 00:11:30,330 to find on x diagnostic test? As opposed 311 00:11:30,330 --> 00:11:31,769 to say, let's wait to see what the 312 00:11:31,769 --> 00:11:33,610 CT shows. It's based off this. I think 313 00:11:33,610 --> 00:11:35,389 the CT show is going to show 314 00:11:36,465 --> 00:11:38,085 either alveolar filling process 315 00:11:38,705 --> 00:11:40,304 here. I if we were to get PFTs 316 00:11:40,304 --> 00:11:42,304 on this patient who has a pulse ox 317 00:11:42,304 --> 00:11:44,865 at 91% on room air at rest, we'd 318 00:11:44,865 --> 00:11:47,125 probably be concerned that there's some diffusion capacity, 319 00:11:47,184 --> 00:11:49,044 so probably an impairment in DLCO. 320 00:11:49,379 --> 00:11:51,299 So just another way to start to frame 321 00:11:51,299 --> 00:11:53,379 what diagnostic test we wanna select and what 322 00:11:53,379 --> 00:11:55,860 we anticipate to see based off the limited 323 00:11:55,860 --> 00:11:58,200 but great data that you've presented so far. 324 00:11:58,580 --> 00:12:00,419 And I'm sure this patient did have some 325 00:12:00,419 --> 00:12:03,355 additional workup done. So, Khalil, any did the 326 00:12:03,355 --> 00:12:05,274 patient get a an ABG in any other 327 00:12:05,274 --> 00:12:07,054 labs that you wanna share at this time? 328 00:12:07,995 --> 00:12:09,995 Yeah. Of course. So the patient the labs 329 00:12:09,995 --> 00:12:12,794 were ordered, including a CBC with DIF and 330 00:12:12,794 --> 00:12:14,414 a complete metabolic profile. 331 00:12:14,889 --> 00:12:17,850 TMP and the CBC was with were with 332 00:12:17,850 --> 00:12:20,570 the normal limits, but an ABG on Lumiere 333 00:12:20,570 --> 00:12:23,709 was mainly notable for a pH of 7.38, 334 00:12:23,769 --> 00:12:25,529 a p c o two of 34, a 335 00:12:25,529 --> 00:12:27,389 p o two of 55, and a bicarbonate 336 00:12:27,610 --> 00:12:29,929 level on the metabolic profile that was of 337 00:12:29,929 --> 00:12:30,429 20. 338 00:12:32,115 --> 00:12:35,075 Thanks, Khalil. This is super helpful. As Christina 339 00:12:35,075 --> 00:12:37,634 was mentioning, we are thinking about etiologies of 340 00:12:37,634 --> 00:12:40,695 hypoxemia now interestingly because he's not hypoxemic 341 00:12:41,315 --> 00:12:43,154 by standard criteria, but I think we all 342 00:12:43,154 --> 00:12:45,690 know that twenty one percent ninety one percent 343 00:12:45,690 --> 00:12:46,970 for a 28 year old in room air 344 00:12:46,970 --> 00:12:47,870 would be abnormal. 345 00:12:48,250 --> 00:12:50,409 And this gives us that same indication. The 346 00:12:50,409 --> 00:12:52,730 PO two is 55. It lines up pretty 347 00:12:52,730 --> 00:12:55,850 nicely with us. And so my first sort 348 00:12:55,850 --> 00:12:57,370 of step on this is if you have 349 00:12:57,370 --> 00:12:59,384 a patient, they have shortness of breath, is 350 00:12:59,384 --> 00:13:01,384 to calculate an AA gradient. And this is 351 00:13:01,384 --> 00:13:02,904 a perfect patient to do that in. They're 352 00:13:02,904 --> 00:13:04,585 not that sick where a lot of the 353 00:13:04,585 --> 00:13:06,184 factors are gonna be changing in the AA 354 00:13:06,184 --> 00:13:08,345 gradient. They're on room air, and they're a 355 00:13:08,345 --> 00:13:11,065 young patient where we have good expected normal 356 00:13:11,065 --> 00:13:13,799 values. And I think all of everyone will 357 00:13:13,940 --> 00:13:15,860 reach back and remember their equation, but f 358 00:13:15,860 --> 00:13:18,580 I o two times atmospheric pressure minus water 359 00:13:18,580 --> 00:13:20,580 pressure, which in our standard, we can simplify 360 00:13:20,580 --> 00:13:22,899 down to one fifty minus p c o 361 00:13:22,899 --> 00:13:25,034 two over 0.8. 362 00:13:25,115 --> 00:13:27,034 That is giving us our sort of metabolic 363 00:13:27,034 --> 00:13:29,034 ratio and profile. And that gives us an 364 00:13:29,034 --> 00:13:32,475 estimation of their alveolar oxygen content. And then 365 00:13:32,475 --> 00:13:33,615 we're subtracting 366 00:13:33,995 --> 00:13:35,754 from that, our p a o two. And 367 00:13:35,754 --> 00:13:37,274 for this patient, we get a gradient of 368 00:13:37,274 --> 00:13:39,595 50, which is certainly well above the normal 369 00:13:39,595 --> 00:13:41,809 expected for someone who's this age, which would 370 00:13:41,809 --> 00:13:43,509 be in the 10 to 20 range. 371 00:13:43,889 --> 00:13:45,649 And so now we have hypoxemia. We have 372 00:13:45,649 --> 00:13:48,769 hypoxemia at rest. And so we could do 373 00:13:48,769 --> 00:13:50,769 other things like giving oxygen, trying to see 374 00:13:50,769 --> 00:13:52,929 how that changes. But we are really starting 375 00:13:52,929 --> 00:13:55,410 to worry here now about a BQ mismatch 376 00:13:55,410 --> 00:13:58,334 or sort of shunt situation. DLCO obviously can 377 00:13:58,334 --> 00:14:00,654 do this as well, but it very unusual 378 00:14:00,654 --> 00:14:03,375 for a 28 year old to have relative 379 00:14:03,375 --> 00:14:06,334 hypoxemia and the elevated gradient at rest, just 380 00:14:06,334 --> 00:14:09,054 from DLCO. We'd really think about exertion as 381 00:14:09,054 --> 00:14:11,149 driving that. And then because you gave us 382 00:14:11,149 --> 00:14:13,070 a metabolic profile, we can also think about 383 00:14:13,070 --> 00:14:15,070 the acid base status. We see in this 384 00:14:15,070 --> 00:14:16,690 that there's a little bit of a metabolic 385 00:14:16,750 --> 00:14:19,950 acidosis with some respiratory compensation. So that's just 386 00:14:19,950 --> 00:14:21,470 something for us to think about as we're 387 00:14:21,470 --> 00:14:24,325 gonna keep approaching this patient. So now our 388 00:14:24,325 --> 00:14:26,804 our differential that had started as that dry 389 00:14:26,804 --> 00:14:29,044 cough, then maybe dry cough or dyspnea, is 390 00:14:29,044 --> 00:14:30,904 now a little bit more focused on hypoxemia 391 00:14:31,205 --> 00:14:33,605 and crackles. And so we can assume that 392 00:14:33,605 --> 00:14:35,924 we're gonna explain those other findings by explaining 393 00:14:35,924 --> 00:14:38,004 this one and kinda move forward the case 394 00:14:38,004 --> 00:14:38,664 from that. 395 00:14:38,990 --> 00:14:41,149 So based on the abnormal exam, based on 396 00:14:41,149 --> 00:14:43,789 that abnormal gas exchange, I'm sure that this 397 00:14:43,789 --> 00:14:46,190 patient is going to get some imaging. So 398 00:14:46,190 --> 00:14:47,950 we will post all the images from this 399 00:14:47,950 --> 00:14:50,129 case so everybody can follow along and review. 400 00:14:50,190 --> 00:14:51,870 But, Cleo, maybe you can walk us through 401 00:14:51,870 --> 00:14:53,009 the imaging studies. 402 00:14:54,465 --> 00:14:56,465 Yeah. They did a chest x-ray on this 403 00:14:56,465 --> 00:14:59,605 patient in the ED, which showed patchy bilateral 404 00:14:59,825 --> 00:15:03,684 infiltrates without any specific regional or lower predilection. 405 00:15:04,465 --> 00:15:07,424 There were no associated mediastinal abnormalities or any 406 00:15:07,424 --> 00:15:08,325 pleural effusions. 407 00:15:09,149 --> 00:15:11,730 So these opacities seem not to be interstitial, 408 00:15:11,870 --> 00:15:14,589 but seem to be to represent actually airspace 409 00:15:14,589 --> 00:15:17,789 disease. The list of differential diagnosis that the 410 00:15:17,789 --> 00:15:20,269 EDI attendings were thinking of seems to be 411 00:15:20,269 --> 00:15:22,110 broad, but at least we can narrow it 412 00:15:22,110 --> 00:15:25,394 down to alveolar processes rather than interstitial ones. 413 00:15:25,774 --> 00:15:28,675 Among the more common alveolar etologies is pneumonia, 414 00:15:28,815 --> 00:15:30,975 might be multifocal in this case, but can 415 00:15:30,975 --> 00:15:32,915 also include aspiration, tuberculosis, 416 00:15:33,295 --> 00:15:33,795 sarcoidosis, 417 00:15:34,415 --> 00:15:37,839 certain types of cancers, either primary, pulmonary, or 418 00:15:37,839 --> 00:15:40,559 metastatic disease to the lung. So, again, we 419 00:15:40,559 --> 00:15:43,360 have various differentials that we might be thinking 420 00:15:43,360 --> 00:15:45,699 of in front of this clinical case. 421 00:15:48,000 --> 00:15:49,759 Thanks, Kaleo. And I think those are really 422 00:15:49,759 --> 00:15:50,579 great differentials 423 00:15:50,879 --> 00:15:53,654 to think about. Right? And probably an exercise 424 00:15:53,654 --> 00:15:55,514 that you could do is list the differentials, 425 00:15:55,654 --> 00:15:57,735 and then as you get more aliquots of 426 00:15:57,735 --> 00:15:58,235 information, 427 00:15:58,615 --> 00:16:01,014 you can move those differentials up and down 428 00:16:01,014 --> 00:16:02,455 based off the data and kind of the 429 00:16:02,455 --> 00:16:03,434 pretest probability. 430 00:16:03,815 --> 00:16:05,575 So I agree. I think that the differential 431 00:16:05,575 --> 00:16:07,379 for this patient is still broad. We're still 432 00:16:07,460 --> 00:16:10,039 keeping in mind this potential mold exposure. 433 00:16:10,820 --> 00:16:12,340 And probably some of these that you said, 434 00:16:12,340 --> 00:16:14,500 an ammonia process, if this has been more 435 00:16:14,500 --> 00:16:15,160 of a subacute 436 00:16:15,700 --> 00:16:18,580 three month process going on, like, I that 437 00:16:18,580 --> 00:16:21,080 can't completely rule that out, but would probably 438 00:16:21,164 --> 00:16:23,804 start to put some rearrange those in certain 439 00:16:23,804 --> 00:16:26,125 instances just to to see. So I would 440 00:16:26,125 --> 00:16:28,845 probably move infectious down lower on my list 441 00:16:28,845 --> 00:16:29,504 of differentials. 442 00:16:29,884 --> 00:16:32,365 But great ones great differentials that that we 443 00:16:32,365 --> 00:16:34,284 have so far. And love for you to 444 00:16:34,284 --> 00:16:35,884 tell us and walk us through what happened 445 00:16:35,884 --> 00:16:36,945 next for this patient. 446 00:16:37,950 --> 00:16:41,409 As you mentioned, infectious etiologies of the presentation 447 00:16:41,629 --> 00:16:44,129 might be less probable, but the ED physicians 448 00:16:44,509 --> 00:16:46,909 mainly addressed it as a possible multifocal community 449 00:16:46,909 --> 00:16:47,730 acquired pneumonia. 450 00:16:48,269 --> 00:16:50,509 And since the patient has a good social 451 00:16:50,509 --> 00:16:53,144 support, mainly his mother at home, he was 452 00:16:53,144 --> 00:16:56,584 discharged on empiric antibiotics with an outpatient pulmonary 453 00:16:56,584 --> 00:16:58,125 clinic follow-up in a week. 454 00:16:58,504 --> 00:17:00,904 However, the patient presented to the ED five 455 00:17:00,904 --> 00:17:03,225 days later with worsening symptoms and with a 456 00:17:03,225 --> 00:17:06,125 cough that has now a blood tinged sputum. 457 00:17:07,619 --> 00:17:09,140 Thanks so much, Cliff, for taking this through. 458 00:17:09,140 --> 00:17:11,619 Yeah. I think that that your explanation is 459 00:17:11,619 --> 00:17:14,259 really right that maybe we have some signs 460 00:17:14,259 --> 00:17:16,180 of not being quite sure of infection. That 461 00:17:16,180 --> 00:17:17,940 being said, we do this all the time. 462 00:17:17,940 --> 00:17:20,259 Like, if common things being common, we have 463 00:17:20,259 --> 00:17:22,119 to still consider it, and 464 00:17:22,634 --> 00:17:24,795 the low risk of an antibiotic course plays 465 00:17:24,795 --> 00:17:26,234 in. But this is an important thing that 466 00:17:26,234 --> 00:17:28,234 comes up as what are we calling community 467 00:17:28,234 --> 00:17:30,234 acquired pneumonia? What when are we starting to 468 00:17:30,234 --> 00:17:31,755 put on our hat to think about some 469 00:17:31,755 --> 00:17:33,914 other things? Seems like he still has something 470 00:17:33,914 --> 00:17:36,795 lingering, could have some superimposed infection at this 471 00:17:36,795 --> 00:17:38,509 point. But, Sabia, I was hoping you could 472 00:17:38,509 --> 00:17:40,269 walk us through CAP. We see and we 473 00:17:40,269 --> 00:17:42,509 treat really often, but there's always this range 474 00:17:42,509 --> 00:17:45,390 of certainty. Sometimes it's super obvious, and sometimes 475 00:17:45,390 --> 00:17:47,069 it's a little subtle. And just hoping you 476 00:17:47,069 --> 00:17:48,509 can talk us through how you think about 477 00:17:48,509 --> 00:17:50,589 this diagnosis and what do you think about 478 00:17:50,589 --> 00:17:51,890 it relative to this case? 479 00:17:52,795 --> 00:17:55,195 Yeah. Thanks so much. Yeah. I think that 480 00:17:55,195 --> 00:17:57,535 Kalia was really right on in terms 481 00:17:58,315 --> 00:18:00,154 of you know, in fact, your CDology seems 482 00:18:00,154 --> 00:18:01,295 a little bit less 483 00:18:01,755 --> 00:18:04,174 likely, but I mean, being 484 00:18:04,579 --> 00:18:06,420 in the ER with all these patients that 485 00:18:06,420 --> 00:18:08,740 come through, I don't blame them for saying, 486 00:18:08,740 --> 00:18:11,380 okay. Maybe you have something superimposed right now. 487 00:18:11,380 --> 00:18:13,059 Let's make sure we take care of this, 488 00:18:13,059 --> 00:18:15,059 and then we'll see. But most of the 489 00:18:15,059 --> 00:18:17,400 time when you're talking about, like, a community 490 00:18:17,460 --> 00:18:18,279 acquired pneumonia, 491 00:18:18,660 --> 00:18:19,400 we really, 492 00:18:19,705 --> 00:18:21,625 you have to have a constellation of symptoms 493 00:18:21,625 --> 00:18:22,684 like fevers, 494 00:18:23,305 --> 00:18:26,105 along with the shortness of breath, maybe having 495 00:18:26,105 --> 00:18:28,845 x-ray findings as so as, like, an alobar 496 00:18:28,904 --> 00:18:29,404 consolidation. 497 00:18:29,945 --> 00:18:32,664 Although you can have these alveolar kind of 498 00:18:32,664 --> 00:18:35,109 infiltrates that can give you this picture of 499 00:18:35,109 --> 00:18:36,409 multifocal pneumonia. 500 00:18:37,349 --> 00:18:39,829 Atypical pneumonia is all those kinds of things, 501 00:18:39,829 --> 00:18:42,809 and there's ground glass opacities that can happen. 502 00:18:42,950 --> 00:18:45,429 And then oftentimes, you give them antibiotics, and 503 00:18:45,429 --> 00:18:47,909 then the pneumonia resolves. In this instance, it 504 00:18:47,909 --> 00:18:50,164 didn't seem that's what happened is this person 505 00:18:50,164 --> 00:18:53,065 comes back to the emergency room with ongoing 506 00:18:53,125 --> 00:18:56,085 symptoms. And in patients who have who are 507 00:18:56,085 --> 00:18:56,585 immunocompromised, 508 00:18:57,204 --> 00:18:59,224 it's really important to give them 509 00:18:59,525 --> 00:19:01,204 antibiotics. And I don't know how much of 510 00:19:01,204 --> 00:19:02,984 this he does have, like, an IgA 511 00:19:03,549 --> 00:19:04,450 kind of nephropathy. 512 00:19:04,829 --> 00:19:07,309 Does this make him somewhat much more symptom 513 00:19:07,390 --> 00:19:09,869 much more likely to have atypical kind of 514 00:19:09,869 --> 00:19:10,369 presentation? 515 00:19:10,910 --> 00:19:13,230 And so something to think about in this 516 00:19:13,230 --> 00:19:13,730 instance. 517 00:19:15,565 --> 00:19:17,724 Totally. And I I think the the we 518 00:19:17,724 --> 00:19:19,965 talked a lot about the diagnostic process. I 519 00:19:19,965 --> 00:19:22,525 like to kinda show flow diagrams, but then 520 00:19:22,525 --> 00:19:24,365 also say the flow diagrams are still just 521 00:19:24,365 --> 00:19:26,365 a probability. Right? And you always have to 522 00:19:26,365 --> 00:19:29,105 factor in the prevalence in the population. 523 00:19:29,509 --> 00:19:31,990 But then we sometimes don't always do the 524 00:19:31,990 --> 00:19:35,049 same really rigorous thought process, the treatment process. 525 00:19:35,110 --> 00:19:37,430 And so it may just be worth having 526 00:19:37,430 --> 00:19:39,590 some treatment to take a question off the 527 00:19:39,590 --> 00:19:42,105 table, especially if that treatment is low risk 528 00:19:42,345 --> 00:19:44,825 tolerated short in duration. And as you say, 529 00:19:44,825 --> 00:19:46,424 when you see sort of these types of 530 00:19:46,424 --> 00:19:48,505 cases in the emergency department, I think with 531 00:19:48,505 --> 00:19:50,605 an infiltrate on imaging and some hypoxemia 532 00:19:50,984 --> 00:19:52,904 is maybe the better part of valor to 533 00:19:52,904 --> 00:19:54,345 even try to treat it and see what 534 00:19:54,345 --> 00:19:56,319 happens. And then take your next steps from 535 00:19:56,319 --> 00:19:59,140 there. Yeah. And especially because he's, like, relatively 536 00:19:59,200 --> 00:19:59,700 young. 537 00:20:00,000 --> 00:20:02,559 So you're you're like, sweating your eyes. I 538 00:20:02,559 --> 00:20:04,559 think that if he was older, it will 539 00:20:04,559 --> 00:20:07,325 be a very different kind of process. Yeah. 540 00:20:07,325 --> 00:20:07,984 Or immunocompromised, 541 00:20:08,285 --> 00:20:10,204 like you indicated. Yeah. It might change things 542 00:20:10,204 --> 00:20:11,265 a little bit as well. 543 00:20:13,404 --> 00:20:16,285 Yeah. Totally agree. So, Kahlil, when this patient 544 00:20:16,285 --> 00:20:18,224 came back then with worsening symptoms, 545 00:20:18,525 --> 00:20:20,500 right, I think this, as I maybe talked 546 00:20:20,500 --> 00:20:22,420 about earlier, alluded to, just you have the 547 00:20:22,420 --> 00:20:22,920 ability 548 00:20:23,700 --> 00:20:26,500 to reassess and renew your diagnostic differential in 549 00:20:26,500 --> 00:20:27,880 the diagnostic process. 550 00:20:28,180 --> 00:20:29,619 So I'd love for you to walk us 551 00:20:29,619 --> 00:20:31,539 through what happened next and what were the 552 00:20:31,539 --> 00:20:33,240 initial thoughts on his representation. 553 00:20:35,015 --> 00:20:37,095 Yeah. They reassessed the patient in the ED, 554 00:20:37,095 --> 00:20:39,654 and they repeated an x-ray. It showed a 555 00:20:39,654 --> 00:20:41,494 similar appearance to the one done on the 556 00:20:41,494 --> 00:20:43,835 first presentation a couple of days prior. 557 00:20:44,375 --> 00:20:47,255 And for to advance in the diagnostic process, 558 00:20:47,255 --> 00:20:49,109 a CT scan of the chest was done, 559 00:20:49,349 --> 00:20:51,849 which showed diffuse ground glass opacities 560 00:20:52,150 --> 00:20:56,009 with, again, no specific location predilection, no consolidation, 561 00:20:56,390 --> 00:20:58,329 no mediastinal or hyaloid lymphadenopathy, 562 00:20:58,710 --> 00:21:01,210 and there was no pleural disease. 563 00:21:04,164 --> 00:21:05,605 Great. And I think I think the CT 564 00:21:05,605 --> 00:21:06,585 scan is definitely 565 00:21:06,964 --> 00:21:09,765 helpful and indicated in here. And and I'd 566 00:21:09,765 --> 00:21:11,044 love and I know in a minute you'll 567 00:21:11,044 --> 00:21:12,404 talk us through a little bit more of 568 00:21:12,404 --> 00:21:14,644 the diagnostic reasoning. But before this, I wanted 569 00:21:14,644 --> 00:21:16,404 to just resummarize the case because I think 570 00:21:16,404 --> 00:21:18,700 this is gonna be a case that you 571 00:21:18,700 --> 00:21:20,940 will continue to see throughout the remainder of 572 00:21:20,940 --> 00:21:22,940 your fellowship and probably a case that a 573 00:21:22,940 --> 00:21:25,740 lot of our listeners today have had the 574 00:21:25,740 --> 00:21:28,000 opportunity to treat and work up as well. 575 00:21:28,140 --> 00:21:29,595 But just to briefly summarize, 576 00:21:30,234 --> 00:21:32,474 young man with a past medical history notable 577 00:21:32,474 --> 00:21:35,034 for Asperger's and social history notable for mold 578 00:21:35,034 --> 00:21:35,534 exposure, 579 00:21:35,914 --> 00:21:39,115 who's presenting with chronic worse who sorry. Who's 580 00:21:39,115 --> 00:21:40,335 presenting with a 581 00:21:40,954 --> 00:21:43,914 chronic worsening cough and dyspnea, now progressing to 582 00:21:43,914 --> 00:21:45,054 small volume hemoptysis, 583 00:21:45,549 --> 00:21:47,329 who's found to have relative hypoxemia 584 00:21:47,630 --> 00:21:49,009 on room air with an elevate 585 00:21:49,630 --> 00:21:51,410 with an elevated AA gradient 586 00:21:51,950 --> 00:21:55,789 and scattered GGO nodules on CT scan. So, 587 00:21:55,789 --> 00:21:57,950 Kahlil, could you share with our listeners how 588 00:21:57,950 --> 00:21:59,809 you would approach this diagnostically? 589 00:22:01,394 --> 00:22:03,634 Thank you, Christina, for the summary. So at 590 00:22:03,634 --> 00:22:06,115 this point, our diagnostic process will be based 591 00:22:06,115 --> 00:22:07,795 on the findings of the CAT scan and 592 00:22:07,795 --> 00:22:09,335 the temporality of the symptoms. 593 00:22:09,715 --> 00:22:12,515 Having ground glass opacities means that the process 594 00:22:12,515 --> 00:22:13,894 is most likely to be alveolar. 595 00:22:14,339 --> 00:22:17,779 Again, differentials remain broad, but the underlying cause 596 00:22:17,779 --> 00:22:19,619 seems to be a subacute one that tends 597 00:22:19,619 --> 00:22:20,359 to be chronic. 598 00:22:20,660 --> 00:22:22,819 Infectious etiologies are less likely in front of 599 00:22:22,819 --> 00:22:23,640 this alveolitis. 600 00:22:24,019 --> 00:22:26,019 And in the setting of exposure to black 601 00:22:26,019 --> 00:22:27,994 mold, hypersensitivity pneumonitis 602 00:22:28,295 --> 00:22:31,335 like doctor Sabia, doctor Hassan actually mentioned, was 603 00:22:31,335 --> 00:22:33,195 high on offered on our different differential. 604 00:22:33,974 --> 00:22:36,375 At this point, blood and sputum cultures returned 605 00:22:36,375 --> 00:22:38,615 negative, and we decided to proceed with the 606 00:22:38,615 --> 00:22:40,715 diagnostic bronchoscopy and the BAL. 607 00:22:41,279 --> 00:22:43,059 We performed the BD bronchoscopy, 608 00:22:43,519 --> 00:22:46,660 and the fluid that came back was turbid, 609 00:22:46,799 --> 00:22:49,860 and cell count was about 9,000, predominantly neutrophilic. 610 00:22:50,559 --> 00:22:52,900 Later on, AFB, respiratory, 611 00:22:53,279 --> 00:22:55,380 and fungal cultures came back negative. 612 00:22:55,884 --> 00:22:57,585 We also performed a hypersensitivity 613 00:22:57,964 --> 00:23:00,765 pneumonitis panel that came back positive for high 614 00:23:00,765 --> 00:23:02,065 titers of antibodies 615 00:23:02,365 --> 00:23:02,865 against, 616 00:23:03,244 --> 00:23:05,505 and be patient with me over here, Oreobacidium 617 00:23:06,045 --> 00:23:07,825 pululans, which is a fungus 618 00:23:08,365 --> 00:23:10,224 frequently found in black mold. 619 00:23:10,669 --> 00:23:12,990 Patient. That was perfect. I'm glad I don't 620 00:23:12,990 --> 00:23:14,529 have to try to pronounce that. 621 00:23:15,150 --> 00:23:16,429 But this is great. I love the way 622 00:23:16,429 --> 00:23:18,750 that you're approaching this case. We seem to 623 00:23:18,750 --> 00:23:20,750 have a patient that had a few things 624 00:23:20,750 --> 00:23:23,549 that could be pointing towards hypersensitivity pneumonitis, and 625 00:23:23,549 --> 00:23:25,365 so we're gonna be aggressive in that workup. 626 00:23:25,365 --> 00:23:27,125 And so I think sending the lab panel 627 00:23:27,125 --> 00:23:30,005 to adjust our pretest probability is gonna be 628 00:23:30,005 --> 00:23:32,265 really helpful. I also think, like, a bronchoscopy 629 00:23:32,325 --> 00:23:33,684 at this point just makes a lot of 630 00:23:33,684 --> 00:23:36,005 sense. Right? Patients come back, failed one course 631 00:23:36,005 --> 00:23:36,664 of antibiotics, 632 00:23:37,125 --> 00:23:39,384 gram last opacity, small volume hemoptysis. 633 00:23:40,079 --> 00:23:42,079 You could think about trying to do other 634 00:23:42,079 --> 00:23:44,159 empiric treatments, but we just have to know 635 00:23:44,159 --> 00:23:47,519 what's going on. And bronchoscopy with cell count, 636 00:23:47,519 --> 00:23:48,019 interestingly, 637 00:23:48,640 --> 00:23:50,640 is part of getting cultures really helpful for 638 00:23:50,640 --> 00:23:53,359 ruling out infections and especially helps us with 639 00:23:53,359 --> 00:23:55,985 atypical infections. Like, we're gonna set it AFP. 640 00:23:55,985 --> 00:23:57,924 We're gonna have a broader respiratory panel. 641 00:23:58,225 --> 00:24:00,705 But, cell count itself can be in the 642 00:24:00,705 --> 00:24:03,265 workup of some of our interstitial lung diseases 643 00:24:03,265 --> 00:24:04,085 and our hypersensitivity 644 00:24:04,545 --> 00:24:07,505 pneumonitis as well. Okay. So this patient now, 645 00:24:07,505 --> 00:24:09,025 we have a bunch of things that are 646 00:24:09,025 --> 00:24:10,245 pointing towards hypersensitivity. 647 00:24:10,880 --> 00:24:13,759 We have a presentation that's consistent, subacute to 648 00:24:13,759 --> 00:24:15,779 chronic, progressive, cough, and hypoxemia. 649 00:24:16,160 --> 00:24:17,920 We have ground glass opacities on the CAT 650 00:24:17,920 --> 00:24:19,279 scan, and we'll post it for you all 651 00:24:19,279 --> 00:24:21,039 to see, but with features that may think 652 00:24:21,039 --> 00:24:22,740 of make us think about hypersensitivity 653 00:24:23,039 --> 00:24:23,619 and pneumonitis. 654 00:24:24,065 --> 00:24:25,825 To say some of these explicitly, I think 655 00:24:25,825 --> 00:24:27,664 we'll talk about it, but there are different 656 00:24:27,664 --> 00:24:29,744 patterns we can see. We can see more 657 00:24:29,744 --> 00:24:32,625 upper lobe distributions and hypersensitivity pneumonitis. We can 658 00:24:32,625 --> 00:24:34,625 see more air trapping and things like that 659 00:24:34,625 --> 00:24:36,325 in association with our ground load, 660 00:24:36,704 --> 00:24:37,444 our GGOs. 661 00:24:38,130 --> 00:24:40,130 We also have a known mold exposure by 662 00:24:40,130 --> 00:24:40,630 history, 663 00:24:40,930 --> 00:24:43,490 and this is now also confirmed based on 664 00:24:43,490 --> 00:24:46,369 an antibody profile. So obviously this is raising 665 00:24:46,369 --> 00:24:47,109 it really high. 666 00:24:47,570 --> 00:24:49,570 There are some things that are not quite 667 00:24:49,570 --> 00:24:51,750 classic. The B a L B and PMN 668 00:24:51,809 --> 00:24:54,554 predominant is not what we classically read about. 669 00:24:54,554 --> 00:24:57,115 We really think about lymphocyte predominant in the, 670 00:24:57,115 --> 00:24:59,194 in the HP process. So we'll just take 671 00:24:59,194 --> 00:25:00,414 those things into consideration. 672 00:25:01,115 --> 00:25:02,714 So clearly you are taking care of this 673 00:25:02,714 --> 00:25:05,275 patient, your fellow, I'm sure, very industrious about 674 00:25:05,275 --> 00:25:06,815 reading about all of these possibilities. 675 00:25:07,279 --> 00:25:08,480 So can you tell us a little bit 676 00:25:08,480 --> 00:25:10,799 more about the diagnosis of HP and how 677 00:25:10,799 --> 00:25:12,179 one comes to that diagnosis? 678 00:25:13,440 --> 00:25:15,759 Sure. Let me start first with a quick 679 00:25:15,759 --> 00:25:16,259 definition. 680 00:25:16,639 --> 00:25:17,139 Hypersensitivity 681 00:25:17,519 --> 00:25:20,319 pneumonitis is a complex ILD caused by exposure 682 00:25:20,319 --> 00:25:21,619 to an inhaled antigen 683 00:25:21,955 --> 00:25:24,835 with many phases, extending from self limiting disease 684 00:25:24,835 --> 00:25:28,275 to relapsing or progressive inflammatory disease to chronic 685 00:25:28,275 --> 00:25:30,215 fibrotic disease resembling IPF. 686 00:25:30,994 --> 00:25:33,875 We categorize patients now as having nonfibrotic or 687 00:25:33,875 --> 00:25:36,690 fibrotic HP. We used to say that patients 688 00:25:36,690 --> 00:25:39,169 might be having acute versus subacute versus chronic 689 00:25:39,169 --> 00:25:42,950 HP, but we were forgetting about this definition. 690 00:25:43,089 --> 00:25:45,089 And the high resolution CT scan of the 691 00:25:45,089 --> 00:25:47,009 chest plays a key role here in the 692 00:25:47,009 --> 00:25:48,149 diagnostic process. 693 00:25:48,845 --> 00:25:52,144 Early disease manifests with ground glass nodules distributed 694 00:25:52,365 --> 00:25:53,825 across all lung zones. 695 00:25:54,205 --> 00:25:57,404 This inflammation leads to small airway narrowing, causing 696 00:25:57,404 --> 00:25:58,625 lobular air trapping. 697 00:25:59,085 --> 00:26:01,404 Sometimes this process might create what we call 698 00:26:01,404 --> 00:26:03,965 a three density pattern, which is a combination 699 00:26:03,965 --> 00:26:05,640 of normal appearing globules, 700 00:26:05,940 --> 00:26:08,740 ground class opacities, and globules of decreased density 701 00:26:08,740 --> 00:26:09,799 and vessel size. 702 00:26:10,259 --> 00:26:12,820 And this CT pattern is highly specific to 703 00:26:12,820 --> 00:26:13,320 HP. 704 00:26:14,259 --> 00:26:16,964 Later in the process, signs of fibrosis might 705 00:26:17,125 --> 00:26:20,184 appear, combining reticular abnormalities, traction bronchiectasis, 706 00:26:21,044 --> 00:26:23,304 loss of lobular volume, and honeycombing. 707 00:26:24,325 --> 00:26:27,605 PFTs, if performed, would show a restrictive pattern, 708 00:26:27,605 --> 00:26:29,444 and the BAL is usually done on these 709 00:26:29,444 --> 00:26:29,910 patients. 710 00:26:30,390 --> 00:26:32,630 Cell count would show high WBC count like 711 00:26:32,630 --> 00:26:35,130 you mentioned, Dave, but differential might be mixed. 712 00:26:35,190 --> 00:26:36,410 It might be neutrophilic 713 00:26:36,789 --> 00:26:39,529 or lymphocytic predominant and tends to be lymphocytic 714 00:26:39,670 --> 00:26:41,609 predominant actually in later stages. 715 00:26:42,725 --> 00:26:44,644 Other work of that what we might be 716 00:26:44,644 --> 00:26:47,845 doing is specific serum IgG tests that can 717 00:26:47,845 --> 00:26:50,744 be valuable to pursue suspicious exposures or point 718 00:26:50,884 --> 00:26:53,625 toward an as yet undetected exposure. 719 00:26:53,940 --> 00:26:55,379 But there is a lack of well defined 720 00:26:55,379 --> 00:26:58,279 predicted values for specific IgGs, and the tests 721 00:26:58,339 --> 00:27:00,679 cannot really differentiate between sensitization 722 00:27:01,059 --> 00:27:01,799 and disease. 723 00:27:02,339 --> 00:27:04,759 So it is mainly a combination of suggestive 724 00:27:04,980 --> 00:27:06,039 history and exposures, 725 00:27:06,625 --> 00:27:09,105 imaging features, and some labs that would lead 726 00:27:09,105 --> 00:27:10,964 us toward a diagnosis of HP. 727 00:27:13,105 --> 00:27:14,704 Thanks so much, Khalil. That was just a 728 00:27:14,704 --> 00:27:15,444 great summary 729 00:27:15,744 --> 00:27:18,464 of what learners should expect when they're thinking 730 00:27:18,464 --> 00:27:19,444 about this in 731 00:27:20,019 --> 00:27:22,660 imaging and history findings that are so important. 732 00:27:22,660 --> 00:27:24,500 And I think such a great teaching pearl 733 00:27:24,500 --> 00:27:27,140 that you also included was really this new 734 00:27:27,140 --> 00:27:27,640 terminology 735 00:27:28,019 --> 00:27:30,900 used to classify hypersensitivity pneumonitis, which is now 736 00:27:30,900 --> 00:27:32,279 nonfibrotic or fibrotic. 737 00:27:32,674 --> 00:27:34,194 So glad that you brought that up. And 738 00:27:34,194 --> 00:27:36,034 for you in training and for others listening 739 00:27:36,034 --> 00:27:38,294 today, can I can now have that framework 740 00:27:38,755 --> 00:27:39,414 as well? 741 00:27:40,115 --> 00:27:42,034 So coming wanna come back to our case, 742 00:27:42,034 --> 00:27:44,194 though. So did you feel that at this 743 00:27:44,194 --> 00:27:46,539 point that this was a a concrete diagnosis? 744 00:27:46,759 --> 00:27:49,079 Were you a % confident on it? Or 745 00:27:49,079 --> 00:27:51,640 were there any other diagnostics that you and 746 00:27:51,640 --> 00:27:53,420 or the team felt needed to be pursued? 747 00:27:54,519 --> 00:27:55,019 Mhmm. 748 00:27:55,320 --> 00:27:57,720 So there was still an uncertainty regarding the 749 00:27:57,720 --> 00:27:59,535 diagnosis of HB in this case. 750 00:28:00,734 --> 00:28:02,815 We opted then to pursue a long biopsy 751 00:28:02,815 --> 00:28:05,134 via VATS, and a sampling of the middle 752 00:28:05,134 --> 00:28:07,775 and right lower lobes showed small airways with 753 00:28:07,775 --> 00:28:10,674 mild chronic inflammation of the epithelium and submucosa, 754 00:28:11,535 --> 00:28:12,674 occasional entraepithelial 755 00:28:13,295 --> 00:28:14,755 eosinophils and neutrophils, 756 00:28:15,380 --> 00:28:19,240 mild smooth muscle hypertrophy, and mild submucosal fibrosis. 757 00:28:19,860 --> 00:28:23,460 Also, on the pathology, there were several poorly 758 00:28:23,460 --> 00:28:26,920 formed non necrotizing granulomas and occasional giant multinucleated 759 00:28:27,299 --> 00:28:29,924 cells adjacent to the small airways, as well 760 00:28:29,924 --> 00:28:31,144 as in the interstitium. 761 00:28:34,085 --> 00:28:36,325 Thanks, Cleo. And I'm sure, in this case, 762 00:28:36,325 --> 00:28:38,484 right, I think the decision to do some 763 00:28:38,484 --> 00:28:40,984 of these more advanced diagnostics, right, the bronchoscopy, 764 00:28:41,759 --> 00:28:43,700 the vats, probably having a multidisciplinary 765 00:28:44,160 --> 00:28:46,000 team, a lot of people probably thinking about 766 00:28:46,000 --> 00:28:48,160 what makes sense for this patient. So thank 767 00:28:48,160 --> 00:28:49,519 you thank you for sharing that, and thank 768 00:28:49,519 --> 00:28:51,380 you for sharing the the pathology 769 00:28:52,000 --> 00:28:53,759 as well. I and I think that this 770 00:28:53,759 --> 00:28:55,599 is gonna be important for trainees. I feel 771 00:28:55,599 --> 00:28:56,924 like some of this is gonna be it's 772 00:28:57,005 --> 00:28:59,164 kinda like board questions that you're writing for 773 00:28:59,164 --> 00:29:01,325 yourself, Khalil, in the future and for those 774 00:29:01,325 --> 00:29:03,085 listening. But there are a number of things 775 00:29:03,085 --> 00:29:04,945 on the biopsy that make the diagnosis 776 00:29:05,485 --> 00:29:07,725 of HP more likely. A couple things that 777 00:29:07,725 --> 00:29:09,965 you mentioned, right, the small airway diseases with 778 00:29:09,965 --> 00:29:12,125 some air trapping on a background of mild 779 00:29:12,125 --> 00:29:12,450 chronic 780 00:29:13,329 --> 00:29:16,609 inflammation is really gets my attention. There's also 781 00:29:16,609 --> 00:29:17,669 some non nepotizing, 782 00:29:18,609 --> 00:29:20,230 as you said, poorly formed granulomas, 783 00:29:20,769 --> 00:29:22,470 some giant cells, and mononuclear 784 00:29:22,849 --> 00:29:23,349 infiltrates. 785 00:29:23,889 --> 00:29:26,049 And there are multiple pulmonary diseases that can 786 00:29:26,049 --> 00:29:26,789 have granulomas, 787 00:29:27,089 --> 00:29:28,785 though, so it is important for us to 788 00:29:28,785 --> 00:29:30,565 think about what process 789 00:29:30,865 --> 00:29:34,325 is here, which other disease manifestations that we 790 00:29:34,384 --> 00:29:36,785 can eliminate, and those that are gonna still 791 00:29:36,785 --> 00:29:38,965 remain at the high highest on our differential. 792 00:29:39,184 --> 00:29:40,945 So, Sabija, I'm wondering if you can share 793 00:29:40,945 --> 00:29:42,865 with us how you think about granulomas on 794 00:29:42,865 --> 00:29:43,765 a lung biopsy. 795 00:29:45,269 --> 00:29:46,730 Yeah. Thanks so much, Christina. 796 00:29:47,109 --> 00:29:49,769 Granulomas is sometimes the bane of our existence, 797 00:29:50,149 --> 00:29:52,630 but we actually often get CAT scans that 798 00:29:52,630 --> 00:29:54,630 have these tiny little nodules that come back 799 00:29:54,630 --> 00:29:55,289 as granulomas. 800 00:29:55,589 --> 00:29:57,429 What does it mean? And so I think 801 00:29:57,429 --> 00:29:59,269 this is a great case to go through 802 00:29:59,269 --> 00:30:00,015 some of that, 803 00:30:00,654 --> 00:30:03,875 as most granulomas are caused by infectious etiologies, 804 00:30:04,095 --> 00:30:05,474 either fungal or mycobacterium. 805 00:30:06,255 --> 00:30:08,515 And remember when you do have granulomas 806 00:30:09,214 --> 00:30:10,974 that you do have to make sure that 807 00:30:10,974 --> 00:30:13,079 those are ruled out. So you have to 808 00:30:13,079 --> 00:30:15,000 make sure that those stains are done, the 809 00:30:15,000 --> 00:30:17,400 AFB stains, and then fungal skin stains are 810 00:30:17,400 --> 00:30:19,480 done, and those are negative, and that you're 811 00:30:19,480 --> 00:30:21,559 watching out for those cultures, which may take 812 00:30:21,559 --> 00:30:23,480 time. So it may take six weeks until 813 00:30:23,480 --> 00:30:26,144 those cultures have come back to definitively say 814 00:30:26,144 --> 00:30:27,204 that this is a noninfectious 815 00:30:27,585 --> 00:30:28,085 etiology. 816 00:30:28,625 --> 00:30:30,644 And so you have your infectious, 817 00:30:31,024 --> 00:30:33,024 as I said, your mycobacterium as well as 818 00:30:33,024 --> 00:30:34,884 your fungal, then then you have your noninfectious 819 00:30:35,184 --> 00:30:35,684 etiologies 820 00:30:36,384 --> 00:30:36,964 of granulomatous 821 00:30:37,345 --> 00:30:37,845 diseases 822 00:30:38,259 --> 00:30:39,799 such as Wegenerous, granulomatosis, 823 00:30:40,419 --> 00:30:43,220 the hypersensitivity pneumonitis that we're entertaining in this 824 00:30:43,220 --> 00:30:43,720 instance, 825 00:30:44,099 --> 00:30:46,759 hot tub, lung disease, as well as aspiration 826 00:30:46,819 --> 00:30:47,319 pneumonia. 827 00:30:47,779 --> 00:30:50,099 Sarcoid is also something that we look at. 828 00:30:50,099 --> 00:30:51,079 Remember, sarcoidosis 829 00:30:51,380 --> 00:30:52,679 is a disease of exclusion, 830 00:30:53,244 --> 00:30:55,164 meaning that you have to exclude every other 831 00:30:55,164 --> 00:30:58,304 ideology before you say this person has sarcoid. 832 00:30:58,845 --> 00:31:00,605 Now one of the things that you guys 833 00:31:00,605 --> 00:31:02,765 were talking about was like this, how do 834 00:31:02,765 --> 00:31:03,424 the granulomas 835 00:31:03,724 --> 00:31:06,125 look like? Are they tight? Are they loose? 836 00:31:06,125 --> 00:31:08,720 What's going on? And that really does help 837 00:31:08,720 --> 00:31:10,419 you differentiate between 838 00:31:10,960 --> 00:31:11,460 different 839 00:31:11,919 --> 00:31:12,419 ideologies. 840 00:31:12,880 --> 00:31:15,779 So when you're having, like, loosely formed granulomas 841 00:31:16,240 --> 00:31:18,659 in the background where you're having these inflammatory 842 00:31:18,960 --> 00:31:19,460 infectious 843 00:31:20,000 --> 00:31:21,139 inflammatory processes, 844 00:31:21,464 --> 00:31:23,724 you're gonna think more along the lines 845 00:31:24,025 --> 00:31:24,684 of hypersensitivity 846 00:31:25,065 --> 00:31:26,204 pneumonitis. Whereas 847 00:31:26,984 --> 00:31:30,265 if you're having really nice tight granulomas, then 848 00:31:30,265 --> 00:31:32,444 you're thinking more along the lines of sarcoid 849 00:31:32,904 --> 00:31:33,964 as something 850 00:31:34,265 --> 00:31:37,065 as the ideology of your patients underlying lung 851 00:31:37,065 --> 00:31:37,440 disease. 852 00:31:38,480 --> 00:31:40,259 So remember that hypersensitivity 853 00:31:40,799 --> 00:31:44,159 pneumonitis has this triad of findings that we 854 00:31:44,159 --> 00:31:46,000 all have been going through a little bit 855 00:31:46,000 --> 00:31:48,259 of. These poorly formed granulomas, 856 00:31:48,960 --> 00:31:50,204 and you're having this 857 00:31:50,605 --> 00:31:52,704 inflammatory and then also multilucleated 858 00:31:53,244 --> 00:31:54,065 giant cells 859 00:31:54,444 --> 00:31:55,664 as part of your pathological 860 00:31:56,284 --> 00:31:56,784 findings. 861 00:31:59,644 --> 00:32:01,484 Thank you for walking through that for us. 862 00:32:01,484 --> 00:32:03,345 I think this is as you said, sometimes 863 00:32:03,565 --> 00:32:06,539 granulomas or biopsy results can be confusing for 864 00:32:06,539 --> 00:32:08,380 us. And and the presence of granuloma is 865 00:32:08,380 --> 00:32:09,819 great because we have something we have to 866 00:32:09,819 --> 00:32:11,659 act upon, but it can be difficult at 867 00:32:11,659 --> 00:32:12,880 times to 868 00:32:13,339 --> 00:32:15,099 to delve through. And so it's really helpful 869 00:32:15,099 --> 00:32:17,259 to have a framework. As you indicated with 870 00:32:17,259 --> 00:32:19,919 this sort of triad for HP, the pathologist 871 00:32:19,980 --> 00:32:21,695 can often say this is very likely to 872 00:32:21,695 --> 00:32:24,015 be HP, but that's not always the case. 873 00:32:24,015 --> 00:32:25,394 We often think of 874 00:32:25,855 --> 00:32:28,815 biopsy and pathology as the goldest of gold 875 00:32:28,815 --> 00:32:30,975 standards in medicine, and it definitely is. I'm 876 00:32:30,975 --> 00:32:32,815 not I think it's always so helpful to 877 00:32:32,815 --> 00:32:33,555 have the information. 878 00:32:33,950 --> 00:32:35,549 But often the pathologist can just tell you 879 00:32:35,549 --> 00:32:37,950 what they see, and that doesn't always tell 880 00:32:37,950 --> 00:32:39,869 you what the diagnosis is. Like you said, 881 00:32:39,869 --> 00:32:42,109 no pathologist is going to write this is 882 00:32:42,109 --> 00:32:43,809 sarcoid based on this biopsy, 883 00:32:44,109 --> 00:32:46,529 but if they have these non necrotizing granulomas 884 00:32:46,750 --> 00:32:48,369 and big mediastinal lymphadenopathy 885 00:32:48,829 --> 00:32:50,835 and they're the right demographic and everything else 886 00:32:50,835 --> 00:32:52,595 has been ruled out, we know that helps 887 00:32:52,595 --> 00:32:55,234 make us a diagnosis. So it's really helpful 888 00:32:55,234 --> 00:32:57,795 to look at slides, read through reports, and 889 00:32:57,795 --> 00:32:59,894 then think about how we integrate that knowledge 890 00:32:59,954 --> 00:33:02,134 into making a final diagnosis for our patient. 891 00:33:03,210 --> 00:33:05,130 So with all of that and our high 892 00:33:05,130 --> 00:33:07,369 pretest probability by the time of biopsy and 893 00:33:07,369 --> 00:33:09,609 then our consistent biopsy results, seems like we 894 00:33:09,609 --> 00:33:11,849 have a good solid diagnosis of HP for 895 00:33:11,849 --> 00:33:13,769 this patient. We are gonna do a whole 896 00:33:13,769 --> 00:33:15,565 episode on the treatment of HP coming up, 897 00:33:15,565 --> 00:33:16,424 so I don't wanna 898 00:33:18,345 --> 00:33:18,409 dive too much into it, but I do 899 00:33:18,409 --> 00:33:19,545 wanna hear a little bit about and the 900 00:33:19,545 --> 00:33:21,225 wrap up of our case. So, Kahlil, can 901 00:33:21,225 --> 00:33:22,904 you tell us about the basic tenants of 902 00:33:22,904 --> 00:33:25,625 treatment for HP and how this patient was 903 00:33:25,625 --> 00:33:26,605 treated and responded? 904 00:33:28,184 --> 00:33:31,404 Sure. The mainstay of treatment is antigen avoidance 905 00:33:31,669 --> 00:33:33,609 and removal of the offending agents. 906 00:33:33,990 --> 00:33:36,470 Steroid therapy is debatable in the management of 907 00:33:36,470 --> 00:33:38,809 HP, but has been used in severe cases. 908 00:33:39,349 --> 00:33:41,049 Here, the patient switched apartments, 909 00:33:41,349 --> 00:33:44,384 so supposedly, he's no longer exposed to mold. 910 00:33:44,545 --> 00:33:46,625 And we also started him on prednisone forty 911 00:33:46,625 --> 00:33:48,704 milligram every day for a month with a 912 00:33:48,704 --> 00:33:50,724 slow taper over the next six months. 913 00:33:51,184 --> 00:33:52,644 Patient improved symptomatically, 914 00:33:53,105 --> 00:33:55,505 and the HS x-ray done six months after 915 00:33:55,505 --> 00:33:57,664 we first saw him showed resolution of the 916 00:33:57,664 --> 00:33:59,204 previously described infiltrates. 917 00:34:00,110 --> 00:34:03,390 That's awesome. Delgrad, he responded. And I cannot 918 00:34:03,390 --> 00:34:06,110 stress enough the importance of antigen avoidance. This 919 00:34:06,110 --> 00:34:08,750 is not always possible, but it's very difficult 920 00:34:08,750 --> 00:34:10,510 to treat a patient if they can't change 921 00:34:10,510 --> 00:34:13,070 their exposure at all, even with medications, just 922 00:34:13,070 --> 00:34:15,255 because they already have this underlying and then 923 00:34:15,255 --> 00:34:16,954 continuous process going on. 924 00:34:17,494 --> 00:34:19,255 This is a really amazing case. We're very 925 00:34:19,255 --> 00:34:21,014 excited we got to do another fellow's case 926 00:34:21,014 --> 00:34:22,855 files, and we thank you guys both for 927 00:34:22,855 --> 00:34:25,335 being here. We love building this network and 928 00:34:25,335 --> 00:34:27,574 getting to know trainees and program directors across 929 00:34:27,574 --> 00:34:30,300 the country, and we're excited to induct Rutgers 930 00:34:30,300 --> 00:34:32,539 University and Robert Wood Johnson Medical Center into 931 00:34:32,539 --> 00:34:34,460 that network. And so we'd love for each 932 00:34:34,460 --> 00:34:36,220 of you just to highlight what you love 933 00:34:36,220 --> 00:34:38,780 about being there, but about your education and 934 00:34:38,780 --> 00:34:41,019 about the program, and we're all ears. So, 935 00:34:41,019 --> 00:34:42,559 Kilo, why don't we start with you? 936 00:34:43,925 --> 00:34:46,324 So what I really like about my training 937 00:34:46,324 --> 00:34:48,664 here at Rutgers Robert Wood Johnson Medical School 938 00:34:48,804 --> 00:34:52,025 is the supervised autonomy that I get. Also, 939 00:34:52,085 --> 00:34:54,485 we do encounter a lot of complex cases 940 00:34:54,485 --> 00:34:56,585 inside the ICU that we have to manage. 941 00:34:56,960 --> 00:34:59,539 Even if we have to manage them autonomously 942 00:34:59,760 --> 00:35:02,739 inside the ICU, as well as the diversity 943 00:35:03,039 --> 00:35:05,299 of cases that we encounter in the pulmonary 944 00:35:05,359 --> 00:35:08,239 clinic. Yeah. We're seeing the best of both 945 00:35:08,239 --> 00:35:10,404 worlds, if I would say, in the outpatient 946 00:35:10,404 --> 00:35:12,344 clopidmonary clinic and the inpatient 947 00:35:12,644 --> 00:35:13,625 ICU setting. 948 00:35:14,644 --> 00:35:15,864 That's great. That's wonderful. 949 00:35:16,324 --> 00:35:17,704 Flavia, anything to add? 950 00:35:18,644 --> 00:35:20,885 Yeah. Echo what Khalil was saying. It's really 951 00:35:20,885 --> 00:35:23,045 fun being at Rutgers. I know we're, like, 952 00:35:23,045 --> 00:35:26,069 between New York City and and Philadelphia, so 953 00:35:26,069 --> 00:35:28,710 we get a lot of diverse cases here. 954 00:35:28,710 --> 00:35:31,510 And it's really fun to teach in this 955 00:35:31,510 --> 00:35:34,549 environment, and Rutgers seems like it's, like, taking 956 00:35:34,549 --> 00:35:36,250 over the entire state. 957 00:35:36,710 --> 00:35:39,574 So I think that in that kind 958 00:35:40,114 --> 00:35:42,355 of environment, we get a lot of very 959 00:35:42,355 --> 00:35:45,394 diverse case case loads. We actually recently had 960 00:35:45,394 --> 00:35:48,114 the the Mexican consulate next door, so we're 961 00:35:48,114 --> 00:35:50,934 getting a lot of it was from throughout 962 00:35:51,074 --> 00:35:54,409 the world, like this hot bodge of individuals. 963 00:35:54,409 --> 00:35:56,010 So we get a lot of different disease 964 00:35:56,010 --> 00:35:56,510 processes. 965 00:35:57,050 --> 00:35:59,130 Wow. That's really interesting. Yeah. The people in 966 00:35:59,130 --> 00:36:01,769 New Jersey, thank you for their extensive network 967 00:36:01,769 --> 00:36:03,230 that's being built. I'm sure. 968 00:36:04,325 --> 00:36:06,365 I know. That sounds fantastic. Sounds like a, 969 00:36:06,485 --> 00:36:10,025 yeah, training program with really diverse patient care, 970 00:36:10,405 --> 00:36:12,565 fantastic education, and what seems like a really 971 00:36:12,565 --> 00:36:14,885 supportive environment. So glad to have you on. 972 00:36:14,885 --> 00:36:16,805 And for those listening today, think of this 973 00:36:16,805 --> 00:36:19,704 as a potential future fellowship home for you. 974 00:36:20,090 --> 00:36:22,010 And as we end our case today, I 975 00:36:22,010 --> 00:36:23,449 know we like to wrap up each case 976 00:36:23,449 --> 00:36:24,670 with a takeaway point. 977 00:36:24,969 --> 00:36:27,289 I think mine today is I'm just gonna 978 00:36:27,289 --> 00:36:30,269 say relisten to Khalil talk about and define 979 00:36:30,329 --> 00:36:30,829 HP, 980 00:36:31,210 --> 00:36:32,730 but I really like to get how you 981 00:36:32,730 --> 00:36:35,974 mentioned we're moving towards this fibrotic, non fibrotic 982 00:36:36,275 --> 00:36:36,775 characterization 983 00:36:37,234 --> 00:36:37,974 of hypersensitivity 984 00:36:38,355 --> 00:36:38,855 pneumonitis. 985 00:36:39,315 --> 00:36:41,714 And I think you also mentioned the triple 986 00:36:41,714 --> 00:36:44,534 density sign, which can sometimes be seen with 987 00:36:44,594 --> 00:36:45,414 with HP. 988 00:36:45,714 --> 00:36:48,275 So just making sure learners remember that and 989 00:36:48,275 --> 00:36:51,859 can their diagnosis and, clinical reasoning when looking 990 00:36:51,859 --> 00:36:54,279 at a patient together. Farf, what about you? 991 00:36:55,059 --> 00:36:56,839 Yeah. Yeah. I think we have a radiology 992 00:36:56,900 --> 00:36:59,299 rounds on the triple density side. We'll repost 993 00:36:59,299 --> 00:37:00,839 it so people can take a look. 994 00:37:01,295 --> 00:37:03,295 I'll build on that. I think Khalil mentioned 995 00:37:03,295 --> 00:37:05,535 something that's really helpful to consider is that 996 00:37:05,535 --> 00:37:06,355 there's this 997 00:37:06,894 --> 00:37:07,954 acute to chronic, 998 00:37:08,575 --> 00:37:11,454 non fibrotic to fibrotic spectrum of HP, and 999 00:37:11,454 --> 00:37:13,454 some of the classic features we think about 1000 00:37:13,454 --> 00:37:16,300 are really more in that chronic HP populations. 1001 00:37:16,599 --> 00:37:18,699 That BAL lymphocytic predominant 1002 00:37:19,159 --> 00:37:21,320 is a lot from the ILD literature, maybe 1003 00:37:21,320 --> 00:37:23,980 a more chronic population, maybe some more fibrosis, 1004 00:37:24,199 --> 00:37:26,599 but can have a neutrophil predominance early on 1005 00:37:26,599 --> 00:37:29,000 in disease probably like this patient did. So 1006 00:37:29,000 --> 00:37:31,385 I'll take that teaching point away. 1007 00:37:32,405 --> 00:37:34,184 Awesome. Kaleel, what about you? 1008 00:37:35,364 --> 00:37:38,885 My teaching point is that high resolution CT 1009 00:37:38,885 --> 00:37:41,864 scan remains the initial standard to diagnose HP 1010 00:37:41,989 --> 00:37:43,690 like you guys highlighted prior. 1011 00:37:44,309 --> 00:37:46,789 And we now use less lung biopsy to 1012 00:37:46,789 --> 00:37:48,489 establish the diagnosis of HP. 1013 00:37:50,630 --> 00:37:51,849 Great. And, Sabia? 1014 00:37:52,869 --> 00:37:54,309 I think and I I'd bring it back 1015 00:37:54,309 --> 00:37:56,744 to the very beginning. I think that a 1016 00:37:56,744 --> 00:37:59,385 very good his history. I always tell my 1017 00:37:59,385 --> 00:38:02,664 fellows, like, concentrate on the history. The patient 1018 00:38:02,664 --> 00:38:05,164 will give you his diagnosis or her diagnosis. 1019 00:38:05,864 --> 00:38:08,184 So I think that this idea that he 1020 00:38:08,184 --> 00:38:09,980 had ongoing symptoms, 1021 00:38:10,280 --> 00:38:12,380 the fact that they had the mold exposure, 1022 00:38:12,760 --> 00:38:13,500 that hypersensitivity 1023 00:38:13,880 --> 00:38:15,960 in humanitis just in the very beginning would 1024 00:38:15,960 --> 00:38:17,820 have been higher higher in my differential. 1025 00:38:18,599 --> 00:38:21,079 And I think we don't emphasize it enough, 1026 00:38:21,079 --> 00:38:24,525 like, really hone down, get exposure 1027 00:38:24,824 --> 00:38:26,684 history, be really meticulous 1028 00:38:26,985 --> 00:38:29,164 about those kinds of things is really important 1029 00:38:29,784 --> 00:38:31,164 in taking care of your patients. 1030 00:38:31,784 --> 00:38:33,864 Yeah. Absolutely. Yeah. If patient told you what 1031 00:38:33,864 --> 00:38:35,385 he had right away, I have black mold 1032 00:38:35,385 --> 00:38:36,925 in my apartment. I love that. 1033 00:38:37,449 --> 00:38:38,890 All right. Thank you both so much for 1034 00:38:38,890 --> 00:38:40,809 joining us. We love doing these episodes. Thank 1035 00:38:40,809 --> 00:38:42,730 you all for listening in. Make sure that 1036 00:38:42,730 --> 00:38:44,890 you like and review wherever you're listening to 1037 00:38:44,890 --> 00:38:46,489 your podcast and tune in two weeks for 1038 00:38:46,489 --> 00:38:47,309 our next episode. 1039 00:38:47,610 --> 00:38:49,849 This episode was written, produced, edited by myself 1040 00:38:49,849 --> 00:38:52,355 and Christina Montemayor and music's original music by 1041 00:38:52,355 --> 00:38:54,295 Eric Rogers. And we'll see you next time. 1042 00:38:55,474 --> 00:38:57,335 See you next time. Thank you. Thanks.