Immune Reconstitution Syndrome (IRS)

It's a condition seen while treating some patients who suffer from AIDS or immunosuppression. After initiating treatment, the immune system begins to recover, and then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.

There are two common IRS scenarios:
• The first is the "unmasking" of an occult opportunistic infection.
• The second is the "paradoxical" symptomatic relapse of a prior infection despite treatment success. In paradoxical IRS, microbiologic cultures are often sterile.

In either scenario, there is hypothesized reconstitution of antigen-specific T cell-mediated immunity with activation of the immune system against persisting antigen, whether present as intact organisms, dead organisms, or debris.

There are two other situations that you must remember in which IRS can occur: neutropenic patients & post-partum women.

Neutropenic patients during recovery can suffer from IRS as their neutrophil counts start to normalize. Post-partum women may also suffer from IRS since pregnancy leads to some degree of immunosuppression which fades away after giving birth.

The signs & symptoms (ssx) are basically your typical inflammatory ssx like fever and pain, but they also change according to the underlying infection.

The most important aspect of the diagnosis of Alzheimer's disease (AD) is the exclusion of treatable forms of dementia. While imaging of the brain may demonstrate diffuse atrophy with thinning of the cerebral gyri and enlargement of the sulci and ventricles in the advanced stages, it is more important to identify mass lesions, such as chronic subdural hematomas, which may account for the symptoms.

Hyperthyroidism increases stroke volume and myocardial contractility, while at the same time decreases peripheral vascular resistance (PVR). This leads to systolic hypertension and a wide pulse pressure.

That's why, in thyrotoxicosis, you're much more likely to see a wide pulse pressure than hypertension.

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The serotonin syndrome may present with a clinical triad of changes in mental state, autonomic hyperactivity and neuromuscular abnormalities (tremor, hyperreflexia and clonus), but milder presentations with only one or two features are common. Life-threatening reactions with hyperthermia may occur.

Serotonin + niacin ( B3 )
اثنينهم يصنعن من نفس ال amino acid الي هو tryptophan
فمن اكو carcinoid tumour
راح يزداد ال serotonin بالمقابل راح يقل ال B3 لان ال tryptophan راح كله بتصنيع ال serotonin راح يصير B3 deficiency او ما يسمى pellagra
Clinical features
4 D
Dermatitis
Diarrhoea
Dementia
Death
Skin finding
Sun exposed areas
Bad sunburn
Blisters scaling

.

هلو شلونكم
اليوم اجانه كيس interesting و حبيت اشارككم بيه، بس هو بعده undiagnosed.

بيشنت ٢٧ سنة ميل، جاي يصير عنده
Recurrent attacks of syncope for 2 months.
BP reading throughout this time is 80/50 mmHg.
قبل هاي الشهرين هو ما قايس الضغط ماله، و ما يعرف اذا الضغط كان هجي او هذا الهبوط جديد.
ECG: normal

و المربض مخلصها يراجع staff و الي ينطونه فقط fluid، و الي ترفع ال BP لغاية 90.

خلال هاي الفترة كلها البيشنت صار عنده
Marked limitation of daily physical activity due to marked weakness and headache.

بعدها راجع اخصائي، سووله echo و Holter و اثنينهن كانن نورمل، فنصحوه يكثر سوائل.

المهم اجانه بـ syncope
و بدينا بالـ ddx مال السنكوب الي شارحينها بالقناة الف مرة
1. Cardiac: structural (like aortic stenosis or pre-ductal corctation of aorta) and electrical
كلش مهم بهذا العمر نستثني الـ Transient electrical causes مثل
Fascicular VT
Brugada syndrome
Catecholaminergic polymorphic VT
و غيرها و غيرها

2. Vascular:
A. aorta (aortic arch syndrome)
رير بس كلش مهم تتذكرها بالفيميل
B. Carotid: vasodilitation like vasovagal attack or anaphylactic shock or anti-hypertensive overdose
C. Vertebral artery: subclavian steal phenomenon

3. Hypotension/shock :
A. hypovolaemic shock
B. Septic shock
C. Obstructive shock: cardiac tamponade and pulmonary embolism
D. Endocrine shock: like adrenal hypo-function
E. Neurogenic shock

اخذنا هستري لمن طحنا صفح 😂😂
تبين هو قبل ٤ سنوات عنده pulmonary TB و ماخذله كورس كامل و صاير eradication.
فـ مباشرة فكرنا بـ
TB adrenalitis (non-autoimmune adrenal insuficiency)

هذا الحجي احنه وصلنا 1L من النورمل سلاين و ماكو ارتفاع بالضغط أبدا.
جبنا أمبولة وحدة من الـ hydrocortisone100 mg و انطيناها وريدي
قسنا الضغط ب ١٥ دقيقه
ارتفع من 80 لـ 105
فـ گلنا ع الاغلب تفكيرنا صحيح.

حولنا الببشنت إلى chest X ray
شو ما رجع النه 😂😂
الظاهر شاف روحه تحسّن
هجي كيس المفروض ما يروح من أدينا 😭😭😭.

تدري هذا البيشنت لو تنطيه anti TB، معناها راح تقتله حرفياً
و هاي عليكم انتم، كلولي ليش

#emergency
#infectious
#endocrine
@AASmedicalbot

الـ Rifampicin يعتبر
Steroid metabolism enhancer

و هو هذا البيشنت عنده ستيرويد قليل، فمن تنطي ريفامبين راح تقلل الـ steroid أكثر و أكثر
و ممكن يدخل البيشنت منك بـ
Adrenal crisis and ends with sudden cardiac death

و هواي reported cases عن الـ TB patients الي توفوا فجأة بعد آخذ كورس anti TB.

اما بالنسبة لمريضنا: راح أنشر صورته و أكتب عليها هجي
Wanted: alive or dead
و أخلي المكافأة عليه
300,000,000 B
مثل لوووفي 😂😂😂😂

خلصنا قصة الـ TB و الـ adrenal.
@AASmedicalbot

I read a case a while ago about a patient with Fever of Unknown Origin (FUO). He was treated with anti-TB drugs and developed jaundice. The patient was later found to suffer from Hodgkin's lymphoma with liver metastasis.

An uncommon side effect of rifampicin is hepatitis as it's entirely metabolized in the liver. It's especially likely if the patient suffers from liver disease, as in our FUO patient.

.

Most common causes of FUO:

• Infection, most commoly TB
• Malignancy
• Connective tissue disorders
• Miscellaneous
• Unidentified causes/spontaneous remission