Infection;

My elderly patient has a WBC count of 60,000 without obvious hematologic malignancy.  How likely is it that his leukocytosis is related to an infection?

FA Manian MD, MPH, , , , , , , , , , , , , , , , , , , , , , , , , Leave a comment

Although extremely high WBC count in the absence of myeloproliferative disease may be associated with solid tumors and other causes, infections are often the most common cause of leukemoid reaction (LR), including tuberculosis, Clostridiodes difficile colitis, shigellosis, salmonellosis, pneumonia, abscesses, as well as  parasitic infections (eg, malaria), fungal infections (mucormycosis), and viral diseases (eg, HIV, EBV, Chickungunya fever).1-4   

In a study of 173 hospitalized patients (mean age 69 y) with leukemoid reaction (defined in this study as WBC ≥30,000/µl), infection was the most common cause of LR (48%), followed by tissue ischemia/stress (28%), inflammation (eg, pancreatitis, diverticulitis without perforation) and obstetric diagnoses (7% each) and malignant tumor (5%).1 

In the same study, the most common infections were “sepsis”, pneumonia and urinary tract infections.  Bacteremia was documented in 13%, while Clostridiodes difficile toxin assay was positive in 7% of patients.  The highest WBC counts were observed in patients with either a positive blood culture or positive C. difficile toxin.  In-hospital mortality rate was very high at 62%.

Similarly, in a study involving 105 hospitalized patients, the most common cause was infection, followed by malignancy and other causes. 2 In a smaller study of 25 patients with “extreme” leukocytosis (defined as WBC ≥50,000/µl) infection was considered the cause in 52% and malignancy in 44% of patients; about one-third were bacteremic (eg, Pseudomonas sp, Streptococcus pneumoniae, E. coli).3

Bonus Pearl: Did you know that besides infections and malignancy, drugs (eg, corticosteroids, epinephrine) and ingestion of ethylene glycol have also been associated with LR? 1,3,4

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References

  1. Potasman I, Grupper M. Leukemoid reaction:Spectrum and prognosis of 173 adult patients. Clin Infect Dis 2013;57:e177-81. https://pubmed.ncbi.nlm.nih.gov/23994818/
  2. Portich JP, Faulhaber GAM. Leudemoid reaction: A 21st-century study. https://pubmed.ncbi.nlm.nih.gov/31765058/
  3. Halkes CJM, Dijstelbloem HM, Eelman Rooda SJ, et al. Extreme leucocytosis: not always leukaemia. The Netherlands J Med 2007;65:248-51. https://pubmed.ncbi.nlm.nih.gov/17656811/
  4. Kumar P, Charaniya R, Sahoo R, et al. Leukemoid reaction in Chickungunya fever. J Clin Diagn Res 2016;10:OD05-OD06. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948452/

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My elderly patient has a WBC count of 60,000 without obvious hematologic malignancy.  How likely is it that his leukocytosis is related to an infection?

How can people with a respiratory virus such as Covid-19 be contagious even when they don’t cough or sneeze?

FA Manian MD, MPH, , , , , , , , , , , , , , , Leave a comment

Couple of factors likely play a role in the transmission of respiratory viruses such as Covid-19 even in the absence of respiratory symptoms: 1. Generation of small droplets through everyday activities such as talking and breathing; 2. Presence of infectious virus in the respiratory tract before onset of symptoms.1-4

Small droplet generation during every day activity: Normal human speech and breathing can yield small particles or droplets that are too small to see by naked eye but are perfectly capable of serving as vehicles for aerial transport (more like hot air balloons than 737’s!) of a variety of communicable respiratory pathogens. 1  These small particles are believed to originate from the mucosal layers coating the respiratory tract as well as from vocal cord adduction and vibration within the larynx.1

In some cool experiments involving normal volunteers,1 the rate of particle emission during normal human speech positively correlated with the loudness of voice, ranging from 1-50 particles/second, irrespective of the language spoken (English, Spanish, Mandarin, or Arabic).  Perhaps, equally intriguing was identification of “speech superemitters”, consistently releasing an order of magnitude more particles than other participants.

Simply counting out loud has been associated with around 2-10 times as many total particles emitted as a single cough, 2 and the percentage of airborne droplet nuclei generated by singing is several times more than that emitted during normal talking and more like that of coughing! 3 Given, these observations, perhaps, the unfortunate outbreak of Covid-19 among members of a church choir in state of Washington 5 is not totally unexpected.

Presence of infectious virus in persons without symptoms:  An estimated 18% to 75% of patients testing positive for Covid-19 have no symptoms. This of course means that irrespective of whether symptoms ever develop, persons with Covid-19 may serve as a source of infection, by just breathing, talking, or singing when around susceptible people.

For these reasons, social distancing and wearing of masks during a pandemic makes sense!

Bonus Pearl: Did you know that infectious viral particles can be recovered from 40% of breath samples of patients with influenza? 6

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 References

  1. Asadi S, Wexler AS, Cappa CD, et al. Aerosol emission and superemission during human speech increase with voice loudness. Scientific Reports 2019;9:2348. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382806/
  2. Loudon RG, Roberts RM. Droplet expulsion from the respiratory tract. Am Rev Resp Dis 1967;435-42. https://doi.org/10.1164/arrd.1967.95.3.435
  3. Loudon RG, Roberts MR. Singing and the dissemination of tuberculosis. Am Rev Resp Dis 1968;98:297-300. DOI: 10.1164/arrd.1968.98.2.297 https://www.atsjournals.org/doi/abs/10.1164/arrd.1968.98.2.297?journalCode=arrd
  4. Lai KM, Bottomley C, McNerney. Propagation of respiratory aerosols by the Vuvuzela. PLoS One 2011;6:e20086. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100331/
  5. Read R. A choir decided to go ahead with rehearsal. Now dozens of members have COVID-19 and two are dead. Los Angeles Times March 29, 2020. https://www.latimes.com/world-nation/story/2020-03-29/coronavirus-choir-outbreak
  6. Yan J, Grantham M, Pantelic J, et al. Infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community. PNAS 2018;115:1081-1086 https://www.pnas.org/content/115/5/1081

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How can people with a respiratory virus such as Covid-19 be contagious even when they don’t cough or sneeze?

Do statins have a role in treating novel Coronavirus infection, COVID-19?

FA Manian MD, MPH, , , , , , , , , , , , , , , , , , , , , , , , Leave a comment

There is currently no firm clinical evidence that statins improve the outcome of COVID-19. However, there are some theoretical reasons for believing that statins may have a role in the treatment of COVID-19.  That’s because beyond their cholesterol lowering action, statins may also have clinically relevant anti-inflammatory and antiviral (pleotropic) properties.  

Anti-inflammatory: Anti-inflammatory effect of statins is well known and is thought to occur through a variety of molecular pathways of the innate and adaptive immune systems as well as attenuation of several circulating proinflammatory cytokines.1 Although observational studies have suggested that statins lower hospitalization and mortality among outpatients hospitalized with infection, pneumonia or sepsis, several randomized controlled trials (RCTs) have failed to show any mortality benefit among ICU patients with sepsis and ARDS treated with statins.2

In contrast, an RCT involving patients with sepsis (majority with pneumonia, mean CRP 195 mg/dL) reported significant reduction in progression to severe sepsis among statin-naïve patients  placed on atorvastatin 40 mg/day at the time of hospitalization.3 So, perhaps timing of statin therapy before florid sepsis and ARDS is an important factor.  

Some have suggested that statins may decrease the fatality rate of a related Coronavirus, Middle East Respiratory Syndrome (MERS) virus, by blunting exuberant inflammatory response that may result in a fatal outcome. 4

Antiviral: Statins may also have antiviral properties, including activity against influenza, hepatitis C virus, Zika and dengue viruses.2,5 Whether statins have activity against coronaviruses such as the agent of COVID-19 is unclear at this time.

It’s interesting to note that cholesterol may have an important role in the membrane attachment, fusion and replication of many enveloped viruses, including influenza.5 Covid-19 is also an enveloped virus.

So what do we do? Based on the current data, it makes sense to continue statins in patients who have known clinical indications for their use and no obvious contraindications because of COVID-19 (eg. rhabdomyolysis).6 As for statin-naïve patients, particularly those in early stages of sepsis and increased risk of cardiovascular events, benefit may outweigh the risk.  Only proper clinical studies will give us more definitive answers.

Bonus Pearl: Did you know that lipids make up a major component of the envelope in enveloped viruses and that cholesterol makes up nearly one-half of total lipid and over 10% the total mass of influenza viruses?

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References

  1. Tousoulis D, Psarros C, Demosthenous M, et al. Innate and adaptive inflammation as a therapeutic target in vascular diseae: The emerging role of statins. J Am Coll Cardiol 2014;63:2491-2502. https://www.sciencedirect.com/science/article/pii/S0735109714011553?via%3Dihub
  2. Fedson DS. Treating the host response to emerging virus diseases: lessons learned from sepsis, pneumonia, influenza and Ebola. Ann Transl Med 2016;4:421. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124618/pdf/atm-04-21-421.pdf
  3. Patel JM, Snaith C, Thickette DR. Randomized double-blind placebo-controlled trial of 40 mg/day of atorvastatin in reducing the severity of sepsis in ward patients (ASEPSIS Trial) Critical Care 2012;16:R231. https://ccforum.biomedcentral.com/track/pdf/10.1186/cc11895
  4. Espano E, Nam JH, Song EJ, et al. Lipophilic statins inhibit Zika virus production in Vero cells. Scientific Reports 2019;9:11461. https://www.nature.com/articles/s41598-019-47956-1
  5. Sun X, Whittaker GR. Role for influenza virus envelope cholesterol in virus entry and infection. J Virol 2003;77:12543-12551. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC262566/
  6. Virani SS. Is there a role for statin therapy in acute viral infections. Am Coll Cardiol March 18, 2020. https://www.acc.org/latest-in-cardiology/articles/2020/03/18/15/09/is-there-a-role-for-statin-therapy-in-acute-viral-infections-covid-19

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Do statins have a role in treating novel Coronavirus infection, COVID-19?

Is the average body temperature in adults lower than 98.6 ᵒF (37 ᵒC)?

FA Manian MD, MPH, , , , , , , , , , , , Leave a comment

Despite the widely-held belief that the normal body temperature is 98.6 ᵒF (37.0 ᵒC), it is becoming increasingly clear that the average body temperature among adults (at least in the U.S.) is actually lower than 98.6 ᵒF (37 ᵒC).

The concept of a single normal body temperature dates way back to the 1800’s, based on measuring axillary temperatures by mercury thermometers. 1 However, a 2001 systematic literature review of 20 studies (1935-1998) of normal body temperature measured in adults found the following mean temperatures: oral 97.5 ᵒF (36.4 ᵒC), rectal 98.4 ᵒF (36.9 ᵒC), tympanic 97.7 ᵒF (36.5 ᵒC), and axillary 97.3 ᵒF (36.3 ᵒC ).  A British study involving >35,000 patients also found a lower mean oral temperature of 97.9 ᵒF (36.6 ᵒC). 2 A 2020 US study of a cohort of >150,000 adults (2007-20017) found a mean oral temperature of 98.1 ᵒF (36.7 ᵒC) in men and 98.2 ᵒF (36.8 ᵒC) in women; these values were lower than that of an earlier cohort (1971-1975). 3

So is the discrepancy between the body temperature in 1800’s and the more recent era due to the differences in measurement techniques or the population? In other words, are we cooling off?

The weight of the evidence suggests that our bodies are cooling!3  The study of an 1860-1940 cohort—presumably using similar thermometer techniques —found a gradual drop in the mean temperature during that period alone. Since axillary temperature (accounting for some of the values in the earlier cohort) is about 1 ᵒC lower than that of oral temperature, the magnitude of the drop in mean temperatures over the past 150 years is likely higher that those reported. 3

Potential explanations for our cooling bodies over the past 2 centuries include reduction in the population level inflammation due to improved standard of living, sanitation, lower incidence of chronic infections. improved dental hygiene, and cooler ambient temperatures. 3

 

Fun Fact: Did you know that in 1851 Carl Wunderlich, a German physician, obtained millions of axillary temperatures from 25,000 patients in Leipzig and thereby established the standard body temperature of 98.6 ᵒF (37 ᵒC)? ᵒ

 

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References

  1. Sund-Levander M, Forsberg C, Wahren LK. Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review. Scan J Caring Sci 2002;16:122-128. https://www.ncbi.nlm.nih.gov/pubmed/12000664
  2. Obermeyer Z, Samra JK, Mullainathan S. Individual differences in normal body temperature: longitudinal big data analysis of patient records. BMJ 2017;359:j5468. https://www.ncbi.nlm.nih.gov/pubmed/29237616
  3. Protsiv M, Ley C, Lankester J, et al. Decreasing human body temperature in the United States since the industrial revolution. Human Biology and Medicine, Jan 7, 2020. DOI: 10.7554/eLife.49555. https://www.researchgate.net/publication/338433061_Decreasing_human_body_temperature_in_the_United_States_since_the_industrial_revolution
Is the average body temperature in adults lower than 98.6 ᵒF (37 ᵒC)?

My hospitalized patient with pneumonia has now suffered an acute myocardial infarction (MI). Can acute infection and MI be related?

FA Manian MD, MPH, , , , , , , , , Leave a comment

Yes! Ample epidemiological studies implicate infection as an important risk factor for MI.1 The increased risk of MI has been observed during the days, weeks, months or even years following an infection.

A 2018 paper reported a several-fold risk of MI during the week after laboratory-confirmed infection caused by a variety of respiratory pathogens such as influenza virus (6-fold), respiratory syncytial virus (4-fold), and other respiratory viruses (3-fold). 2 Among patients hospitalized for pneumococcal pneumonia, 7-8% may suffer an MI.3,4 One study found a 48-fold increase in the risk of MI during the first 15 days after hospitalization for acute bacterial pneumonia.5 Similarly, an increase in the short-term risk of MI has been observed in patients with urinary tract infection and bacteremia.6

The risk of MI appears to be the highest at the onset of infection and correlates with the severity of illness, with the risk being the highest in patients with pneumonia complicated by sepsis, followed by pneumonia and upper respiratory tract infection. Among patients with pneumonia, the risk exceeds the baseline risk for up to 10 years after the event, particularly with more severe infections.1

Potential mechanisms of MI following infections include release of inflammatory cytokines (eg, interleukins 1, 6, tumor necrosis factor alpha) causing activation of inflammatory cells in atherosclerotic plaques, in turn resulting in destabilization of the plaques. In addition, the thrombogenic state of acute infections, platelet and endothelial dysfunction may increase the risk of coronary thrombosis at sites of plaque disruption beyond clinical resolution of the acute infection. 1

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References

  1. Musher DM, Abers MS, Corrales-Medina VF. Acute infection and myocardial infarction. N Engl J Med 2019;380:171-6. https://www.ncbi.nlm.nih.gov/pubmed/30625066
  2. Kwong JC, Schwartz KL, Campitelli MA, et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018;378:345-53. https://www.nejm.org/doi/full/10.1056/NEJMoa1702090
  3. Musher DM, Alexandraki I, Graviss EA, et al. Bacteremic and nonbacteremic pneumococcal pneumonia: a prospective study. Medicine (Baltimore) 2000;79:210-21. https://www.ncbi.nlm.nih.gov/pubmed/10941350
  4. Musher DM, Rueda Am, Kaka As, Mapara SM. The association between pneumococcal pneumonia and acute cardiac events. Clin Infect Dis 2007;45:158-65. https://www.ncbi.nlm.nih.gov/pubmed/17578773
  5. Corrales-Medina VF, Serpa J, Rueda AM, et al. Acute bacterial pneumonia is associated with the occurrence of acute coronary syndromes. Medicine (Baltimore) 2009;88:154-9. https://www.ncbi.nlm.nih.gov/pubmed/19440118
  6. Dalager-Pedersen M, Sogaard M, Schonheyder HC, et al. Risk for myocardial infarction and stroke after community-acquired bacteremia: a 20-year population-based cohort study. Circulation 2014;129:1387-96. https://www.ncbi.nlm.nih.gov/pubmed/24523433

 

My hospitalized patient with pneumonia has now suffered an acute myocardial infarction (MI). Can acute infection and MI be related?

My patient with cirrhosis now has an upper gastrointestinal bleed (UGIB) with hepatic encephalopathy (HE). What’s the connection between UGIB and HE?

FA Manian MD, MPH, , , , , , , , , , , , , , , , , , , , , , , Leave a comment

Hepatic encephalopathy (HE) may be precipitated by a variety of factors including infection, hypovolemia, electrolyte imbalance (eg, hyponatremia, hypokalemia), metabolic alkalosis, sedatives, and of course UGIB. 1-3

Ammonia is often considered to play a central role in the the pathogenesis of HE, particularly when associated with UGIB. The ammoniagenic potential of UGIB is primarily attributed to the presence of hemoglobin protein in the intestinal tract. One-half of the ammoniagenesis originates from amino acid metabolism (mainly glutamine) in the mucosa of the small bowel, while the other half is due to the splitting of urea by the resident bacteria in the colon (eg, Proteus spp., Enterobacteriaceae, and anerobes).1,2

A large protein load in the GI tract, as occurs in UGIB, may result in hyperammonemia in patients with cirrhosis due to the limited capacity of the liver to convert ammonia to urea through the urea cycle as well as by the shunting of blood around hepatic sinusoids. Recent studies, however, also implicate the kidneys as an important source of ammonia in this setting, further compounding HE.3

It’s important to stress that ammonia is not likely to be the only mediator of HE. Enhanced production of cytokines due to infection or other inflammatory states, neurosteroids, endogenous benzodiazepines, and other bacterial byproducts may also play an important role in precipitating HE.2,4-6  So stay tuned!

Bonus pearl: Did you know that proinflammatory cytokines tumor necrosis factor-alpha and inerleukin-6 increase ammonia permeability across central nervous system-derived endothelial cells? 7

 

References

  1. Olde Damink SWM, Jalan R, Deutz NEP, et al. The kidney plays a major role in the hyperammonemia seen after simulated or actual GI bleeding in patients with cirrhosis. Hepatology 2003;37:1277-85.
  2. Frederick RT. Current concepts in the pathophysiology and management of hepatic encephalopathy. Gastroenterol Hepatol 2011;7:222-233.
  3. Tapper EB, Jiang ZG, Patwardhan VR. Refining the ammonia hypothesis: a physiology-driven approach to the treatment of hepatic encephalopathy. Mayo Clin Proc 2015;90:646-58.
  4. Shawcross DL, Davies NA, Williams R, et al. Systemic inflammatory response exacerbates the neuropsychological effects of induced hyperammonemia in cirrhosis. J Hepatol 2004;40:247-254.
  5. Shawcross DL, Sharifi Y, Canavan JB, et al. Infection and systemic inflammation, not ammonia, are associated with grade ¾ hepatic encephalopathy, but not mortality in controls. J Hepatol 2011;54:640-49.
  6. Shawcross D, Jalan R. The pathophysiologic basis of hepatic encephalopathy: central role for ammonia and inflammation.Cell Mol Life Sci 2005;62:2295-2304.
  7. Duchini A, Govindarajan S, Santucci M, et al. Effects of tumor necrosis factor-alpha and interleukin-6 on fluid-phase permeability and ammonia diffusion in CNS-derived endothelial cells. J Investig Med 1996;44:474-82.

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My patient with cirrhosis now has an upper gastrointestinal bleed (UGIB) with hepatic encephalopathy (HE). What’s the connection between UGIB and HE?

My previously healthy patient is admitted with a multi-drug resistant E. coli urinary tract infection. Could her urinary tract infection (UTI) be foodborne?

FA Manian MD, MPH, , , , , , , Leave a comment

Yes! Although foodborne infections are often thought to cause infections limited to the GI tract, an increasing number of studies have linked foodborne E.coli to extraintestinal infections in humans, including UTIs.1

Supportive data include frequent genetic similarly between antimicrobial-resistant E. coli from humans and poultry-associated E. coli. 2 In fact, antimicrobial-resistant E. coli isolates from humans may be  genetically more similar to poultry isolates than susceptible commensal E. coli strains in the human GI tract.3

A U.S. study found that 14% of chicken meat products were contaminated with E. coli strains capable of causing extraintestinal disease, 1/3 of which were mutli-drug resistant.4  Another study found that 94% of retail chicken meat samples contained E. coli with ESBL-genes,  of which nearly 40% contained isolates present in humans.5

Among women, UTI caused by antimicrobial-resistant extraintestinal pathogenic E. coli has been linked to high levels of self-reported chicken consumption.6

The plausibility of foodborne transmission of antimicrobial-resistant E. coli to humans is further supported by the finding that drug resistant E coli from chicken carcasses widely contaminate the kitchen during meal preparation and can appear in the intestinal tract of those who prepare such food.2

Bonus Pearl: Did you know that women with multi-drug resistant E. coli UTI are 3.7 times more likely to report frequent consumption of chicken? 6

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References

  1. Manges AR. Escherichia coli and urinary tract infections: the role of poultry-meat. Clin Microbiol Infect 2016;22:122-29. https://www.ncbi.nlm.nih.gov/pubmed/26679924
  2. Manges AR, Johnson JR. Reservoirs of extraintestinal pathogenic Escherichia coli. Microbiol Spectrum 2012;3(5):UTI-0006-2012. https://www.ncbi.nlm.nih.gov/pubmed/26542041
  3. Johnson JR, Menard M, Johsnton B, et al. Epidemic clonal groups of Escherichia coli as a cause of antimicrobial-resistant urinary tract infections in Canada, 2002 to 2004. Antimicrob Agents Chemother 53;2733-2739. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704706/
  4. Johnson JR, Porter SB, Johnston B, et al. Extraintestinal pathogenic and antimicrobial-resistant Escherichia coli, including sequence type 131 (ST131) from retail chicken breasts in the United States in 2013. Apppl Environ Microbiol 83:e02956-16. https://www.ncbi.nlm.nih.gov/pubmed/28062464
  5. Leverstein-van Hall MA, Dierikx CM, Stuart JC, et al. Dutch patients, retail chicken meat and poultry share the same ESBL genes, plasmids and strains. Clin Microbiol Infect 2011;17:873-880. https://www.ncbi.nlm.nih.gov/pubmed/21463397
  6. Manges AR, Smith SP, Lau BJ, et al. Retail meat consumption and the acquisition of antimicrobial resistant Escherichia coli causing urinary tract infections: a case-control study. Foodborne Path Dis 4:419-431. https://www.ncbi.nlm.nih.gov/pubmed/18041952

 

My previously healthy patient is admitted with a multi-drug resistant E. coli urinary tract infection. Could her urinary tract infection (UTI) be foodborne?

Does erythrocyte sedimentation rate (ESR) have diagnostic utility in my patient with chronic renal failure?

FA Manian MD, MPH, , , , , , , , , , Leave a comment

Short answer: often not! This is because most studies have shown frequently high ESR’s in stable “uninflamed” patients with chronic renal failure (CRF) (including those on dialysis) at levels often associated with infection, connective tissue disease, or malignancy. 1-4  

In fact, in a study involving patients with CRF, 57% of patients had markedly elevated ESR (greater than 60 mm/h), with 20% having ESR greater than 100 mm/h; type or duration of dialysis had no significant effect on ESR levels.1 Another study reported a specificity for abnormal ESR of only 35% for commonly considered inflammatory conditions (eg, infections or malignancy) among patients with CRF. 2

But is it the chronic inflammation in diseased kidneys or the uremic environment that elevates ESR? A cool study compared ESR in CRF in patients who had undergone bilateral nephrectomies with those with retained kidneys and found no significant difference in the ESR between the 2 groups. 4  So it looks like it’s the uremic environment, not diseased kidneys themselves that result in elevated ESR in these patients.

The mechanism behind these observations seem to reside entirely within the patients’ plasma, not the erythrocytes. Within the plasma, fibrinogen (not gammaglobulins) seem to be the most likely factor explaining elevated ESR among patients with CRF. 1,2

Bonus pearl:  Did you know that ESR is nearly 100 years old, first described in 1921? 5

References

  1. Barthon J, Graves J, Jens P, et al. The erythrocyte sedimentation rate in end-stage renal failure. Am J Kidney Dis 1987;10: 34-40. https://www.ncbi.nlm.nih.gov/pubmed/3605082
  2. Shusterman N, Morrison G, Singer I. The erythrocyte sedimentation rate and chronic renal failure. Ann Intern Med 1986;105:801. http://annals.org/aim/fullarticle/700910
  3. Arik N, Bedir A, Gunaydin M, et al. Do erythrocyte sedimentation rate and C-reactive protein levels have diagnostic usefulness in patients with renal failure? Nephron 2000;86:224. https://www.ncbi.nlm.nih.gov/pubmed/11015011
  4. Warner DM, George CRP. Erythrocyte sedimentation rate and related factors in end-stage renal failure. Nephron 1991;57:248. https://www.karger.com/Article/PDF/186266
  5. Fahraeus R. The suspension stability of the blood. Acta Med Scan 1921;55:70-92. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.0954-6820.1921.tb15200.x

 

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Does erythrocyte sedimentation rate (ESR) have diagnostic utility in my patient with chronic renal failure?

How is prealbumin related to albumin?

FA Manian MD, MPH, , , , , , , , , , , , Leave a comment

Aside from being synthesized in the liver and serving as a transport protein in the blood, prealbumin (PA) doesn’t really have much in common with albumin. More specifically, PA is not derived from albumin and, in fact, the two proteins are structurally distinct from each other!

So where does PA get its name? PA is the original name for transthyretin (TTR), a transport protein that primarily carries thyroxine (T4) and a protein bound to retinol (vitamin A). The name arose because TTR migrated faster than albumin on gel electrophoresis of human serum.1

Because of its much shorter serum half-life compared to that of albumin ( ~2 days vs ~20 days),2 PA is more sensitive to recent changes in protein synthesis and more accurately reflects recent dietary intake (not necessarily overall nutritional status) than albumin. 3

But, just like albumin, PA may represent a negative acute phase reactant, as its synthesis drops during inflammatory states in favor of acute phase reactants such as C-reactive protein. 4 So be cautious about interpreting low PA levels in patients with active infection, inflammation or trauma.

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Reference

  1. Socolow EL, Woeber KA, Purdy RH, et al. Preparation of I-131-labeled human serum prealbumin and its metabolism in normal and sick patients. J. Clin Invest 1965; 44: 1600-1609. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC292644/
  2. Oppenheimer JH, Surks MI, Bernstein G, and Smith JC. Metabolism of Iodine-131-labeled Thyroxine-Binding Prealbumin in Man. Science 1965; 149: 748-750. https://www.ncbi.nlm.nih.gov/pubmed/14330531
  3. Ingenbleek Y, Young VR. Significance of prealbumin in protein metabolism. Clin Chem Lab Med 2002; 40: 1281-1291. https://www.ncbi.nlm.nih.gov/pubmed/12553432
  4. Shenkin A. Serum prealbumin: is it a marker of nutritional status or of risk of malnutrition? Clin Chem 2006;52:2177 – 2179. http://clinchem.aaccjnls.org/content/52/12/2177

Contributed by Colin Fadzen, Medical Student, Harvard Medical School, Boston, MA.

 

 

How is prealbumin related to albumin?

How accurate are peripheral thermometers for estimating body temperature in my patient with chills?

FA Manian MD, MPH, , , , , , , , Leave a comment

Though convenient, oral, tympanic membrane, axillary, and temporal artery thermometers (AKA “peripheral thermometers”) may not be highly accurate in measuring body temperature.

A 2015 systematic review and meta-analysis of the performance of peripheral thermometers involving 75 studies (mostly in adults) found that compared to central thermometers (eg, pulmonary artery, urinary bladder, rectal), peripheral thermometers had a low sensitivity (64%, 95% CI 55%-72%), but much better specificity (96%, 95% CI 93%-97%) for fever (most commonly defined as 37.8° C [100° F] or greater).1

In the same study, for oral electronic thermometers, sensitivity was 74% with a specificity of 86%. For temporal artery thermometers, sensitivities ranged from 26% to 91%, while specificities ranged from 67% to 100%. For tympanic membrane thermometers, sensitivities ranged from 23% to 87%, with a specificity of 57% to 99%.

A 2016 study involving adult emergency department patients reported the sensitivity of peripheral thermometers (vs rectal temperature 38 C [100.4] or higher) as follows: oral (37%), tympanic membrane (68%), and temporal artery (71%). Specificity for fever was >90% for all peripheral thermometers. 2

So, it looks like while we may be pretty comfortable with a diagnosis of “fever” when our patient with chills has a high temperature recorded by a peripheral thermometer, lack of fever alone by these devices should not veer us away from the possibility of systemic infection. When in doubt and if possible, check a rectal temperature.

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References

  1. Niven DJ, Gaudet JE, Laupland KB. Accuracy of peripheral thermometers for estimating temperature: A systematic and meta-analysis. Ann Intern Med 2015;163:768-777. https://www.ncbi.nlm.nih.gov/pubmed/26571241
  2. Bijur PE, Shah PD, Esses D. Temperature measurement in the adult emergency department: oral tympanic membrane and temporal artery temperatures versus rectal temperature. Emerg Med J 2016;33:843-7. https://www.ncbi.nlm.nih.gov/pubmed/27334759

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How accurate are peripheral thermometers for estimating body temperature in my patient with chills?