Wacky ID Case

[docB]

Advertisement - Members don't see this ad

40 M presents with a complaint of mouth and throat pain getting worse for 4 weeks.

Pt is a homosexual with a long history of dental problems. 6 weeks ago he had extractions of his remaining teeth so he could be fitted with dentures. He began wearing his new dentures about a week after the extraction. About a week after that his mouth and throat began to hurt and he has been unable to eat. He has lost 40 pounds in the ensuing 4 weeks.

I was expecting to see some sequelae of the dental procedure such as abscess, dry socket, etc. On exam patient has obvious florid thrush of the oral cavity and pharynx.

Oops. Full mental reset. The dental procedure is a red herring. I now have a homosexual male with 40 pounds of weight loss and thrush. So for the students, what is this?




















That is a very typical presentation for HIV. Actually it would be AIDS as the thrush (when it is esophageal as it was in this patient) is an AIDS defining illness.
CDC Paper on AIDS Defining Illnesses
Wikipedia article on AIDS Defining Illnesses which is a pretty good summary.

So I admitted the patient to the resident medicine service for work up and treatment. He couldn't tolerate PO so admission was indicated.

Now since this is a wacky case you know it can't be that simple 😀. It was not HIV. What could it be?

























I followed the patient to see if I was right about my presumed diagnosis of HIV. HIV tests were all negative. T Cell counts were normal. ID confirmed oral, pharyngeal and esophageal thrush. What was this?

The medicine intern, taking a history like only an intern can, discovered the truth. The patient began wearing his dentures and using denture adhesive about a week before the onset of symptoms. He was just finishing the course of antibiotics he was given for the dental extractions. When he would take out his dentures at night he didn't like the feeling of the left over adhesive on his gums. So of course he began using a nail file to abrade away the left over adhesive on his gums every night. This would, of course, be the same nail file he uses to file his thickened, discolored, onchomycotic toenails.😱

None of us, including ID, really knew if you could directly seed your mouth with the fungus from your toenails. Is it the same species of fungus? Regardless, we were pretty sure that antibiotics to kill off normal flora + repetitive abrasion with a dirty nail file was not the way to go for good oral hygiene.

This was definitely a new one on me.

 

[Aznfarmerboi]

40 M presents with a complaint of mouth and throat pain getting worse for 4 weeks.

Pt is a homosexual with a long history of dental problems. 6 weeks ago he had extractions of his remaining teeth so he could be fitted with dentures. He began wearing his new dentures about a week after the extraction. About a week after that his mouth and throat began to hurt and he has been unable to eat. He has lost 40 pounds in the ensuing 4 weeks.

I was expecting to see some sequelae of the dental procedure such as abscess, dry socket, etc. On exam patient has obvious florid thrush of the oral cavity and pharynx.

Oops. Full mental reset. The dental procedure is a red herring. I now have a homosexual male with 40 pounds of weight loss and thrush. So for the students, what is this?




















That is a very typical presentation for HIV. Actually it would be AIDS as the thrush (when it is esophageal as it was in this patient) is an AIDS defining illness.
CDC Paper on AIDS Defining Illnesses
Wikipedia article on AIDS Defining Illnesses which is a pretty good summary.

So I admitted the patient to the resident medicine service for work up and treatment. He couldn't tolerate PO so admission was indicated.

Now since this is a wacky case you know it can't be that simple 😀. It was not HIV. What could it be?

























I followed the patient to see if I was right about my presumed diagnosis of HIV. HIV tests were all negative. T Cell counts were normal. ID confirmed oral, pharyngeal and esophageal thrush. What was this?

The medicine intern, taking a history like only an intern can, discovered the truth. The patient began wearing his dentures and using denture adhesive about a week before the onset of symptoms. He was just finishing the course of antibiotics he was given for the dental extractions. When he would take out his dentures at night he didn't like the feeling of the left over adhesive on his gums. So of course he began using a nail file to abrade away the left over adhesive on his gums every night. This would, of course, be the same nail file he uses to file his thickened, discolored, onchomycotic toenails.😱

None of us, including ID, really knew if you could directly seed your mouth with the fungus from your toenails. Is it the same species of fungus? Regardless, we were pretty sure that antibiotics to kill off normal flora + repetitive abrasion with a dirty nail file was not the way to go for good oral hygiene.

This was definitely a new one on me.

good story

 

[Stitch]

Definitely not where I was expecting that to go.

Totally gross though!

 

[willow18]

Ewwww. Like one of my IM attendings used to say: if the socks are still on, you haven't completed your physical exam.

A month of onchomycosis on the general medicine floor instilled in me a new respect for podiatrists.

 

[Praziquantel86]

That's disgusting. So as far as the weight loss goes, he was in enough pain to almost completely stop eating for four weeks and he didn't seek medical attention? I don't know which of the two things is more stupid...

 

[DrQuinn]

Holy crap. that's disgusting. but yeah i would have done the same exact workup and plan. YUCK!

 

[drewpydog]

Great case. Unfortunately, my favorite part was the vomiting emoticon at the bottom - haven't had a laugh like that in awhile. Thanks.

 

[paiute]

He was just finishing the course of antibiotics he was given for the dental extractions.

the emoticon is great...

no, i don't think the use of the toenail file in the mouth did this. toenail fungus is not typically candida.

i think the antibiotics removed the "protective" normal mouth flora, so the candida overgrew. candida is a normal constituant of the gi flora.

 

[paiute]

another thought: does this pt use methamphetamine. i hear it causes bad gum disease (meth mouth). does he suffer from chronic dry mouth? why did he loose all his teeth?

 

[WilcoWorld]

Three things:

1 - Every time I start to forget DocB's MVP status on this forum I am soon reminded by a post such as this.

2 - This case is a good example of a work-up that turned out to be wrong, but was the right thing to do. Something our consulting colleagues don't always understand.

3 - I actually liked Stich's emoticon more.

 

[docB]

no, i don't think the use of the toenail file in the mouth did this. toenail fungus is not typically candida.

i think the antibiotics removed the "protective" normal mouth flora, so the candida overgrew. candida is a normal constituant of the gi flora.

another thought: does this pt use methamphetamine. i hear it causes bad gum disease (meth mouth). does he suffer from chronic dry mouth? why did he loose all his teeth?

I suspect there was at least a history of meth. I think the tox was negative on this admit though. I can't recall the last patient I had who didn't have at least some meth history, and horrible teeth. He was also a smoker. That didn't help.

I think the nail file contributed in that abrading one's gums daily produces a lot of tissue breakdown and mucosal breaks for infection. It'd be like brushing your teeth with a stick.

This case is a good example of a work-up that turned out to be wrong, but was the right thing to do. Something our consulting colleagues don't always understand.

That's a good point.

 

[freakystud]

lol. never thought that would go that way.. a new one fo rme too..lol

 

[Tzips]

And here I though the solution for those who couldn't be bothered to use a toothbrush is to go the full mouth extraction/complete dentures route... but now I see that I'm mistaken.

And a nil file - whatever possessed him to use a nail file? Even if he had no toothbrush, we give out denture brushes!

That is quite possibly the nastiest story I've heard, topping even the patient who tried to extract her non-periodontally-involved molar with a butter knife🙁

 

[Laryngophed]

40 M presents with a complaint of mouth and throat pain getting worse for 4 weeks.

Pt is a homosexual with a long history of dental problems. 6 weeks ago he had extractions of his remaining teeth so he could be fitted with dentures. He began wearing his new dentures about a week after the extraction. About a week after that his mouth and throat began to hurt and he has been unable to eat. He has lost 40 pounds in the ensuing 4 weeks.

I was expecting to see some sequelae of the dental procedure such as abscess, dry socket, etc. On exam patient has obvious florid thrush of the oral cavity and pharynx.

Oops. Full mental reset. The dental procedure is a red herring. I now have a homosexual male with 40 pounds of weight loss and thrush. So for the students, what is this?




















That is a very typical presentation for HIV. Actually it would be AIDS as the thrush (when it is esophageal as it was in this patient) is an AIDS defining illness.
CDC Paper on AIDS Defining Illnesses
Wikipedia article on AIDS Defining Illnesses which is a pretty good summary.

So I admitted the patient to the resident medicine service for work up and treatment. He couldn't tolerate PO so admission was indicated.

Now since this is a wacky case you know it can't be that simple 😀. It was not HIV. What could it be?

























I followed the patient to see if I was right about my presumed diagnosis of HIV. HIV tests were all negative. T Cell counts were normal. ID confirmed oral, pharyngeal and esophageal thrush. What was this?

The medicine intern, taking a history like only an intern can, discovered the truth. The patient began wearing his dentures and using denture adhesive about a week before the onset of symptoms. He was just finishing the course of antibiotics he was given for the dental extractions. When he would take out his dentures at night he didn't like the feeling of the left over adhesive on his gums. So of course he began using a nail file to abrade away the left over adhesive on his gums every night. This would, of course, be the same nail file he uses to file his thickened, discolored, onchomycotic toenails.😱

None of us, including ID, really knew if you could directly seed your mouth with the fungus from your toenails. Is it the same species of fungus? Regardless, we were pretty sure that antibiotics to kill off normal flora + repetitive abrasion with a dirty nail file was not the way to go for good oral hygiene.

This was definitely a new one on me.

I was satisfied when I thought it was HIV. Damn you for that. I think I'll go bleach my mouth now. Sans nail file.

 

[Flushot]

Amazing story and great write up to boot.

I'm just curious about one thing though: is homosexuality still a notable indicator for HIV? If you had said he was sexually active, I would've thought about it, but is just being homosexual a sign of such an infection?

 

[docB]

Amazing story and great write up to boot.

I'm just curious about one thing though: is homosexuality still a notable indicator for HIV? If you had said he was sexually active, I would've thought about it, but is just being homosexual a sign of such an infection?

He was sexually active.

 

[Doctor Bob]

If you had said he was sexually active, I would've thought about it, but is just being homosexual a sign of such an infection?

I just assume that all people over the age of 12 are sexually active with their partner of choice until proven otherwise.

 

[Flushot]

I get that, but I figured you would say "Pt states they are sexually active" rather than merely stating their sexual preference. I understand the point though.

 

[Eta Carinae]

Amazing story and great write up to boot.

I'm just curious about one thing though: is homosexuality still a notable indicator for HIV? If you had said he was sexually active, I would've thought about it, but is just being homosexual a sign of such an infection?

I get that, but I figured you would say "Pt states they are sexually active" rather than merely stating their sexual preference. I understand the point though.

In fact, the inclusion of the sexual orientation of the patient was a vital detail in the patient’s history. As HIV is most easily transmitted via anal contact, its prevalence is highest in Men who have sex with men/MSM/homosexual males.

As this most recent report from the cdc shows, male-to-male sexual contact accounts for the highest number of adult and adolescent male AIDS cases through 2007 (487,695), Injection drug use being a distant second at 175,704.

In answer to your question then, yes, male-to-male sexual contact is still the strongest risk factor for HIV infection and provides the most efficient means of HIV transmission.

I am amazed that anyone would consider the assignment of that category a belying of pejorative intent.

In medicine, in contradistinction to other fields, hyper vigilance to political correctness can constitute a great disservice to the patient. Details such as a patient’s race or sexual orientation can aid in honing the ddx list and in targeting the requisite diagnostic workup, speeding up the patient’s care and preventing delays that could result in further deterioration of the patient’s condition.

And based on race or lifestyle, certain conditions are routinely monitored or observed for. For AAs, HTN; for elderly caucasian women, osteoporosis, for women with multiple heterosexual partners, HPV. Nothing discriminatory in making those distinctions.




…So I would say this was a 40y/o homosexual male.

 

[JeetKuneDo]

Pretty cool, sort of like a house episode.