Episode 274 and 275 Recap

Authors: Priyanka Athavale and Marcela Santana

This week, we had two incredible episodes: a schema episode discussing an interesting
case of non-resolving pneumonia and eosinophilia and an Anti-Racism in Medicine
episode deconstructing the racialization of substance use and the opioid epidemic in
healthcare.

The schema episode reviewed the case of a 56 year old man presenting with cough, fever,
and shortness of breath, with a leukocytosis notable for eosinophilic predominance. He
was initially given a provisional diagnosis of community acquired pneumonia (CAP) but did
not have adequate response to therapy. A computed tomography scan showed a left apical
consolidation with cavitary nodule. Additional testing was positive for coccidioidomycosis
immunofixation with a titer 1:32, confirming a diagnosis of pulmonary coccidioidomycosis.

In the ARM episode, we hear from experts in the field, Dr. Ayana Jordan and Dr. Jessica
Isom. We learn about the racialization and criminalization of substance use in the United
States and how structures and systems exacerbated this social phenomenon. We delve
into how these ideas are shaped by the media narrative, and hear from these incredible
experts regarding tangible approaches to drug policy reform, including methadone
prescription regulation and decreasing police presence in substance use treatment
settings.

Teaching Points
Community acquired pneumonia (CAP):
Definition: pneumonia acquired 48 hours after hospitalization or in a patient
with a ventilator
 Approach: Think”: “3 plus or minus 1” →
1) presence of acute inflammation; 2) inflammation localizing to
alveoli; 3) response to empiric therapy or CAP.
“Plus or minus 1” is the presence of a microbiologic diagnosis (e.g.
RSV, urine antigen testing, sputum culture, blood culture).
Note: With #1 and #2, we can give the patient a provisional diagnosis of
CAP, but we have to use response to therapy to really confirm the
hypothesis. If they don’t improve, they may not have a CAP. Consider
causes of antibiotic failure. Alternatively, they could have a CAP but
with complications like an airway disease (e.g. obstructed airway),
pleural disease (e.g. empyema (which can be an issue with source
control) or effusion), or parenchymal pathology.
Diffuse lung nodules→ 3 patterns: centrilobular, perilymphatic and randomly
distributed nodules
Centrilobular: include diseases spread through the airways such as airway
infections and noninfectious airway disease like aspiration or endobronchial
tumors)
Perilymphatic: diseases that get to the lungs through lymphatic vessels like
sarcoidosis or certain malignancies
Random: represent disseminated infection like mycobacteria and fungi

CPS Emails Team

Anna Fretz, Priyanka Athavale, Gurleen Kaur, Kara Lau, Gurbani Kaur, Chloe
Cattle, Sukriti Banthiya, Sherry Chao, Laura Araujo, Marcela Santana, and
Andrew Sanchez
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