WDx Clinical Unknown with Dr. Steph Sherman and the CPSolvers

Associated Schema

Problem Representation
A 35-year-old man with advanced HIV/AIDS complicated by a recent diagnosis of Pneumocystis pneumonia and cytomegalovirus esophagitis presented with progressive fevers, dyspnea, and worsening pulmonary infiltrates in the weeks after starting antiretroviral therapy. 

Schemas
The CPSolvers’ schema for dyspnea highlights the relative importance of the pulmonary and cardiovascular systems before considering other etiologies.

Diagnosis
The patient was found to have extensive bilateral consolidations on computed tomography of the chest. Laboratory evaluation demonstrated an elevated alkaline phosphatase, an increase in his CD4 count from 22 to 43 per cubic millimeter, and a reduction in his HIV viral load from > 1 million to 3000 copies. Ultimately, a respiratory culture from his prior admission grew Mycobacterium avium complex, raising the question of whether direct infection with this pathogen or an inflammatory reaction to it in the setting of immune reconstitution could account for his clinical deterioration.

Teaching points

• Mycobacterium avium complex (MAC) is the most common of the nontuberculous mycobacteria (NTM) that acts as a human pathogen. Clinical manifestations are varied, most typically presenting as a chronic pulmonary infection in immunocompetent individuals and either localized (e.g., affecting the lymph nodes or other focal sites) or disseminated infection in immunocompromised patients (especially those with HIV infection). In the early HIV epidemic, disseminated MAC was the most common bacterial opportunistic infection and conferred significant morbidity and mortality even with treatment.
• The immune reconstitution inflammatory syndrome (IRIS) is a potential complication of antiretroviral therapy (ART), wherein patients with advanced immunosuppression related to HIV develop an inflammatory response (generally to microbial antigens) as their immune system recovers. The two main types of IRIS are (1) paradoxical IRIS, in which a patient with a known opportunistic infection on appropriate therapy appears to deteriorate clinically after starting ART, and (2) unmasking IRIS, in which a previously silent opportunistic infection becomes clinically apparent due to the newly present immune response. IRIS to MAC most commonly presents with peripheral lymphadenitis, pulmonary-thoracic manifestations, or intra-abdominal findings.
• Female physicians face many challenges in the clinical environment. Among the most frequently experienced microaggressions is “role misidentification,” or incorrect identification of an individual’s contribution to the health care team (e.g., assuming a female physician is a nurse). It has been suggested that frequent role misidentification (both on the part of patients as well as other healthcare team members) can lead to anxiety and a loss of sense of professional credibility among female trainees.
  • A pilot study recently demonstrated that distribution of new staff badges with the occupational title prominently displayed (i.e., reading “Doctor”) led to a significant improvement in role identification.
  • Additionally, others have suggested that a more deliberate use of professional titles (i.e., introducing female physicians as “Dr. X”) may also serve to combat stereotype threat and role misidentification.