Nejm Pearls

Front 1

ECG finding of acute pericarditis

Back 1

Diffuse ST elevation and PR segment depression initially. With T wave depression later

Hint 1

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 2

Brugada syndrome

Back 2

Sudden cardiac death in Asian young man with RBBB and ST elevation in V1-V3

Hint 2

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 3

ECG finding of cocaine use

Back 3

ST elevation with early repolarization.
Use of cocaine may lead to coronary thrombosis, vasospasm, arrhythmia, aortic dissection and accelerated atherosclerosis

Hint 3

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 4

ECG finding of major pulmonary embolism

Back 4

sinus tachycardia, RBBB, S wave in lead I, Q wave in lead III, or T wave inversion in lead III

Hint 4

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 5

Skin changes of amyloidosis

Back 5

Purpura & ecchymoses. Factor X binding by amyloid fibrils may be partly responsible

Hint 5

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 6

Common finding of antiphosholipid syndrome

Back 6

Stroke, recurrent pregnancy loss, livedo recitularis, purpura, thrombocytopenia, pulmonary embolism

Hint 6

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 7

Common finding of cryoglobulinemia

Back 7

Palpable purpura, Raynaud phenomenon, digital ischemia. Type I is associated with hyperviscosity and thrombosis

Hint 7

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 8

Common finding of hereditary hemorrhagic telangiectasia

Back 8

Mucosal and pulmonary AV malformation lead to epistaxis and GI bleeding, paradoxical embolism with stroke and brain abscess

Hint 8

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 9

Common finding of thrombotic thrombocytopenic purpura

Back 9

Anemia, hemolysis, thrombocytopenia, confusion, fever, renal involvement, myocardial infarction

Hint 9

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 10

What is the common cause of multifocal vascular lesion

Back 10

Vasculitis, e.g. cryoglobulinemia. SLE.
Hypercoagulable state, e.g. antiphosholipid syndrome.
Endocarditis and cholesterol emboli

Hint 10

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 11

How to manage suspected subacute endocarditis?

Back 11

Culture three blood samples, drawn 1hr apart at separate sites. Start empirical board spectrum antibiotics once all blood sample have been obtained

Hint 11

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 12

What should be tested for culture-negative endocarditis?

Back 12

Coxiella, Bartonella, Legionella, Clamydia species. HACEK bacteria (Haemophilus aphrophilus; Actinobacillus, cardiobacterium, Eikenella, Kingella)

Hint 12

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 13

Causes of painful purple toes

Back 13

Peripheral arterial disease;
Cellulitis;
Cryoglobulinemia
Phlegmasia cerulae dolens

Hint 13

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 14

Cause of painful purple toes (1)

Back 14

peripheral arterial disease

Hint 14

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 15

Cause of painful purple toes (2)

Back 15

Cellulitis

Hint 15

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 16

Classification of cryoglobulinemia

Back 16

Type I: monoclonal IgG or IgM, occurs in the presence of multiple myeloma or Waldenstrom's macroglobulinemia
Type II: polyclonal IgG bound to monoclonal IgM. Associated with hepatitis C
Type III: polyclonal IgG bound to polyclonal IgM. occurs in SLE, Sjogren's syndrome and other autoimmune diseases

Hint 16

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 17

What is cryoglobulinemia?

Back 17

Condition caused by immunoglobulins precipitate out of serum at the temperature below 37C

Hint 17

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 18

What is the common association of cryoglobulinemia?

Back 18

MembranoProliferative GlomeruloNephritis; fever; arthralgias, neuropathy;

Hint 18

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 19

What is the diagnosis

Back 19

Cryoglobulinemia

Hint 19

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 20

What is the diagnosis?

Back 20

Phlegmasia cerulea dolens

Hint 20

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 21

What is the diagnosis

Back 21

Phlegmasia cerulea dolens

Hint 21

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 22

What is the diagnosis

Back 22

Phlegmasia cerulea dolens

Hint 22

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 23

What is the manifestation of Phlegmasia cerulea dolens

Back 23

Severe leg pain, edema, bluish discoloration of the toes

Hint 23

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 24

What is the cause of phlegmasia cerulea dolens

Back 24

Cancer, heparin-induced thrombocytopenia, pregnancy, antiphospholipid syndrome

Hint 24

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 25

Management of phlegmasia cerulea dolens

Back 25

anticoagulation, aggressive management with thrombolysis or thrombectomy

Hint 25

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 26

What is the most likely symptom?

Back 26

Left homonymous hemianopia

Hint 26

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 27

Risk factor: prosthetic heart valve. Casual organism for culture negative endocarditis?

Back 27

Aspergillus species

Hint 27

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 28

Risk factor: exposure to kitten. Casual organism for culture negative endocarditis?

Back 28

Bartonella henselae

Hint 28

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 29

Risk factor: homeless and body lice. Casual organism for culture negative endocarditis?

Back 29

Bartonella quintana (urban trench fever)

Hint 29

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 30

Risk factor: consumption of unpasteurized dairy product. Casual organism for culture negative endocarditis?

Back 30

Brucella melintensis

Hint 30

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 31

Risk factor: exposure to birthing animals Casual organism for culture negative endocarditis?

Back 31

Coxiella burnetii (Q fever)

Hint 31

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 32

Risk factor: poor dentition. Casual organism for culture negative endocarditis?

Back 32

HACEK bacteria

Hint 32

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 33

Management in preventing recurrent thromboembolism in patient with active cancer and thrombosis?

Back 33

Low-Molecular-Weight-Heparin. LMWH is superior than warfarin in preventing thrombosis (CLOT trial)

Malnutrition, drug interactions, and vomiting from chemotherapy may make dosing warfarin more problematic.

Hint 33

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 34

What is the alternative anticoagulation in heparin-induced thrombocytopenia patient?

Back 34

Argatroban. Direct thrombin inhibitor

Hint 34

http://content.nejm.org/cgi/interactive-case/361/25/e58/

Front 35

What is the cause of hypercoagulability of cancer patient?

Back 35

1. Tissue factor driven thrombosis
2. Mucin-producing tumors
3. Chemotherapy
4. Immobility
5. Deep venous compression by tumor or lymph nodes

Hint 35

http://content.nejm.org/cgi/interactive-case/361/25/e58/