Internal Medicine Insights 🧠

Todd paresis
also known as Todd paralysis or Todd palsy, is a common syndrome associated with weakness or paralysis in part or all of the body after a seizure. It most commonly affects one limb or half of the body but can have a wide range of presentations.

Abelacimab

is an investigational human monoclonal antibody targeting both inactive and active Factor XI, a key coagulation factor. Its mechanism of action involves potent and sustained Factor XI inhibition, leading to a significant reduction in Factor XI levels and prolongation of the activated partial thromboplastin time (aPTT). Pharmacokinetic advantages include a reduced risk of drug-drug interactions due to its non-metabolism via the cytochrome P-450 system and lack of P-glycoprotein substrate activity. Furthermore, dosage adjustments are not required for age, renal, or hepatic impairment. Clinical trials are currently evaluating abelacimab's efficacy and safety in various indications. The ongoing LILAC-TIMI 76 trial is assessing its potential in atrial fibrillation patients unsuitable for standard anticoagulation therapies. Additionally, the ASTER and MAGNOLIA trials are comparing abelacimab with established anticoagulants (apixaban and dalteparin, respectively) for venous thromboembolism prophylaxis in cancer patients. Abelacimab remains an investigational agent and is not yet approved for any therapeutic use.

If a patient with lupus Is admitted for fever, it is essential to rule out infection prior to attributing the fevers to lupus, especially if they are already on immunosuppres-
slve medications.

Renal biopsies are crucial in any
lupus patient presenting with
renal insufficiency orproteinuria and typlcally show a prollferatlve glomeruloneptuitis. lmmuno- fluorescence shows •tun house" staining (e.g., positive for lgG, lgA, lgM, C3, and Cl q).

There Is often an ESR/CRP discrepancy in active lupus, witli a very high ESR and only mildly elevated CRP. If a patient with lupus lias a very high CRP, infection must be ruled out.

Always look at a patient's albumin prior to calculating anion gap and correct a normal anion gap for the patient's serum albumin. For example, if the albumin is 2 g/L (normal is 3.5 to 5.0), the patient's normal anion gap is 5. If the albumin is normal, assume the anion gap is near 10.

As CKD progresses, reductions in GFR dramatically impair clearance of insulin by the kidney. This may manifest as improved glycemic control.

Anemia in patients with CKD is primarily due to erythropoietin deficiency and is treated to a target hemoglobin of 9 to 11 g/ dL with erythropoiesis-stimulating agents (ESAs). Blood transfusions should be avoided in potential kidney transplant recipients to prevent antibody formation.

High urine output after obstruction relief is described as postobstructive diuresis. Urine output should be replaced with hypotonic fluid to prevent volume depletion. Electrolytes should be monitored and replaced often

Not all black stool is GI bleeding!
Iron or bismuth consumption can turn stool black.
Epistaxis or gum bleeding can lead to melena.

Patients with cirrhosis can take
acetaminophen, just make sure it's less than 2000 mg/day

It is not necessarily abnormal to be able to palpate the liver below the costal margin, though in adults it is generally abnormal to have a palpable spleen.

(COPD)🫁
clubbing is generally absent, even in the presence of hypoxia. The occurrence of clubbing should prompt consideration of alternative diagnoses such as idiopathic pulmonary fibrosis (IPF) or lung cancer, as these conditions are more commonly associated with digital clubbing.

Patients with systemic lupus erythematosus (SLE) should practice sun avoidance and protection, as ultraviolet (UV) light can trigger not only cutaneous lupus but also systemic manifestations of the disease.

* Topiramate-induced renal tubular acidosis (RTA) is a mixed form, not fitting neatly into traditional classifications.
* It inhibits carbonic anhydrase, leading to:
* Reduced bicarbonate reabsorption in the proximal tubules (similar to type 2 RTA).
* Impaired hydrogen ion excretion in the distal tubules (resembling type 1 RTA).
* This results in metabolic acidosis with an inappropriately high urine pH.
* Unlike classical RTA, it's usually associated with normal or mild hypokalemia.
* Clinical effects like nephrolithiasis or bone disorders can often be managed with potassium citrate.

Febuxostat (black box warning regarding CV disease)

Probenecid: not effective in renal failure

For symptomatic treatment of acute gout in
CKD, low-dose colchicine or intra-articular/ oral glucocorticoids are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs).

Pickwickian syndrome
is the combination of severe obesity, a plethoric face and obstructive sleep apnoea causing hypoxia and hypercapnia, resulting in marked daytime somnolence. It is named after the ‘fat and red-faced boy in a state of somnolency’ as described in the novel The Pickwick Papers by Charles Dickens.

Common clinical characteristics of sarcoidosis include:

• Skin:
Erythema nodosum – caution, not always on the shins

Lupus pernio – red crusty lesions, often around the nose
Annular lesions

• Polyuria:
Secondary to hypercalciuria/hypercalcaemia (can also cause renal calculi and nephrocalcinosis)
Secondary to central diabetes insipidus

• Cardiac:
Ventricular arrhythmias
Conduction defects
Cardiomyopathy
Congestive cardiac failure

• Neurological:
Involvement of CNS occurs in 2%
Cranial diabetes insipidus

• Ocular:
Anterior uveitis
Conjunctivitis
Retinal lesions
Keratoconjunctivitis sicca and lacrimal gland enlargement
Optic neuritis

• Metabolic:
Hypercalcaemia and hypercalciuria

• Bone and joints:
Arthralgia
Bone cysts

• Others:
Hepatosplenomegaly
Löfgren syndrome (acute sarcodosis) – triad of bihilar lymphadenopathy, arthritis and erythema nodosum.

• BTS Recommendation on Repeat X-ray: Not recommended routinely for all patients with pneumonia before discharge or at six weeks.

• BTS Recommendation on Chest X-ray After Six Weeks: Recommended for patients with persistent symptoms, physical signs, or higher risk of malignancy.

• Patients at Higher Risk of Malignancy: Smokers and those aged over 50 years. • BTS Recommendation on Repeat X-ray: Not recommended routinely for all patients with pneumonia before discharge or at six weeks.

• BTS Recommendation on Chest X-ray After Six Weeks: Recommended for patients with persistent symptoms, physical signs, or higher risk of malignancy.

• Patients at Higher Risk of Malignancy: Smokers and those aged over 50 years.

Lateral medullary syndrome, also known as Wallenberg syndrome
occurs when the lateral medulla and the inferior surface of the cerebellum are affected by an infarction. This condition results in deficits that involve specific areas of the brain, including the nucleus ambiguous, trigeminal nucleus, vestibular nuclei, cerebellar peduncle, spinothalamic tract, and autonomic fibers.

• Nystagmus
• Ipsilateral involvement of the V and VIII cranial nerves
• Ipsilateral Horner syndrome
• Ipsilateral ataxia
• Crossed pattern of sensory loss
• Pain and temperature sensation are lost on the ipsilateral face and contralateral trunk and limbs.


The syndrome can be caused by an occlusion of any of the five following arteries: the posterior inferior cerebellar artery, vertebral artery, superior lateral medullary artery, middle lateral medullary artery, or inferior lateral medullary artery.

Occlusion of the inferior division of the MCA is nearly always embolic.
• This is typically seen following heart surgery.
• The non-dominant hemisphere involvement leads to anosognosia, unilateral neglect, dressing apraxia, and constructional apraxia.
• These findings reflect the non-dominant parietal lobe involvement.
• A superior quadrantanopia is due to involvement of the optic radiations deep to the second temporal convolution.

Frontotemporal dementia is an insidious condition which manifests in one of three patterns:
• behavioural variant (including rituals, loss of inhibition and change in motivation without depression, all manifesting in this stem)
• semantic dementia (loss of vocabulary)
• progressive non-fluent aphasia (grammatical errors and changes in comprehension).

The Tensilon test can be positive in other neuromuscular conditions and is not specific to MG.

The 6th-nerve nucleus is encircled by seventh-nerve fibres in the pons, so pontine lesions of the seventh cranial nerve are often associated with a convergent squint (due to lateral rectus palsy). Causes include pontine tumours (such as a glioma), demyelination due to multiple sclerosis and vascular lesions.

In this patient with acute pyelonephritis due to obstructive uropathy, emergency surgical intervention should be made to decompress the urinary tract. Indications for emergency surgery are:
• confirmed complicated urinary tract infection due to obstructing stones
• bilateral obstruction and acute kidney injury (AKI)
• unilateral obstruction with AKI in a solitary functioning kidney.

The Kidney Disease: Improving Global Outcomes (KDIGO) organisation does not recommend routine screening of autosomal dominant polycystic kidney disease (ADPKD) patients, except in the following situations:
• Family history of intracerebral aneurysm (ICA) or subarachnoid haemorrhage.
• Personal history of previous ICA rupture.
• Patients with a high-risk profession (e.g., aeroplane pilot).
• Patient anxiety despite being given adequate information regarding risk.

Nephrogenic systemic fibrosis (NSF) is a super rare condition that happens to people with kidney disease after they’ve had an MRI with gadolinium-based contrast agents. It’s more common with older MRI gadolinium agents, so it’s still happening, but it’s pretty rare now. Nephrologists are still debating it. It looks like systemic sclerosis, but it doesn’t have autoimmune antibodies. And guess what? Post-MRI dialysis doesn’t seem to make it any less likely.

A Jarisch–Herxheimer reaction is a body’s response to endotoxin-like substances released when bacteria are killed during antibiotic treatment. It’s been linked to syphilis, Lyme disease, leptospirosis, and relapsing fever. It usually happens 1 to 12 hours after the first antibiotic dose and doesn’t happen again with subsequent treatments. Symptoms include feeling tired, fever, redness, and a fast heartbeat. This can sometimes lead to low blood pressure because the blood vessels in the extremities dilate.

Procaine penicillin can cause a serious reaction if accidentally given IV instead of IM. It’s like a sudden rush of fear, with delusions and hallucinations. Patients might need help restraining themselves. The reaction usually goes away within 20 minutes. Sometimes, patients might have a seizure, which should be stopped with IV or PR diazepam.

• Purpuric rash
• Raynaud’s
• Polyarthralgia
• Positive rheumatoid factor (RF)
• Low C4
• Suggestive of
cyroglobulinaemia

The 2019 revised International Prognostic Scoring System for Waldenström’s Macroglobuinaemia (IPSSWM) allows risk stratification of patients with WM
according to the following factors:
• age < 65 years (0 point)
• age 66–75 years (1 point)
• age > 75 years (2 points)
• beta-2 microglobulin > 4 mg/l (1 point)
• lactate dehydrogenase (LDH) level > 250 IU/l (1 point)
• serum albumin < 35 g/l (< 3.5 g/dl) (1 point).
Risk groups are defined as (with points needed and 5-year survival rate in brackets): very low risk (0 points; 95%); low risk (1 point; 86%); intermediate risk (2 points; 78%); high risk (3 points; 47%); and very high risk (4–5 points; 36%). This patient can be stratified as being intermediate risk due to beta-2 microglobulin and LDH levels.

Mucosa-associated lymphoid tissue lymphoma (MALToma), also known as marginal zone lymphomas, are low-grade lymphomas that predominantly affect the stomach. They exhibit a unique association with chronic inflammation of one of the following types:

- Stomach: Chronic H. pylori gastritis
- Eyes: Sjögren syndrome
- Thyroid: Hashimoto’s thyroiditis
- Intestine: Crohn’s disease or coeliac disease

Treatment against H. pylori is effective and leads to regression in 90% of low-grade gastric MALTomas. Given the significance of establishing H. pylori diagnosis, if the tumor biopsy is negative for H. pylori, non-invasive testing such as stool antigen testing or urea breath test for H. pylori should be performed. In the event of a positive non-invasive test result, the patient should be initially managed with triple therapy.

Teduglutide
is a special medicine that helps the small intestine grow. It’s especially helpful for people with short bowel syndrome caused by many surgeries for Crohn’s disease. After six months of taking Teduglutide, people with short bowel syndrome who needed extra nutrition through a tube (TPN) saw a big drop in how much TPN they needed. Some people needed 20% less, while others needed 100% less!

insulin-related worsening of heart failure and fluid overload
which occurs because insulin itself promotes salt and water retention.

The Scandinavian Simvastatin Survival Study (4S) was a randomised trial of cholesterol lowering in 4444 patients with coronary artery disease.

The CAPRIE trial was a randomised, blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events; it demonstrated an 8.7% relative risk reduction with respect to ischaemic events versus aspirin.

The First International Study of Infarct Survival (ISIS-1) revealed an improved survival in a randomised trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction.