DIP Episode 437 - Infectious Populations (IV Drug Users)

All right, welcome. My name is Divine. This is episode 437 of the Divine Intervention Podcasts. And to this podcast, I'm going to be addressing a topic I like to call infectious populations. I'd like to call this infectious populations. This is an infectious disease podcast, but it's really hard to categorize things here. It's basically a grab bag of very high-yield weird things you miss. You'll you examine that one you may not find in many resources to it may be very poorly defined because it cuts across many different things. Many of these things are almost like situational scenarios. Things you kind of need to keep in mind. So let's go ahead and jump in. So what if they give you a question about an IV drug user that comes to the physician because for the last few days he has noticed he's alone of his skin. He has not been doing particularly well. He has been feeling nauseous, having mouth fevers and things like that. And they ask what is going to be your next best step in diagnosis. I would really hope you're saying a divine. I'm going to go ahead and make sure that I screen this person for the hepatitis viruses, especially HEPB. Especially HEPB. Now, obviously you're still going to screen for HEPC as well. But maybe let me concentrate on these IV drug users for a bit because the many of these weird things they love to go after with these people on exams.

The first thing is if a person that is an IV drug user presents with all these John Dees and elevated AST, ALT and things like that. It's pretty high-yield to know that these people you need to screen them for the viral hepatitis. So like HEPB, HEPC. HEPB, HEPC, those are pretty big ones that you need to make sure that you screen these people for. Now, remember people that also are IV drug users. Many times it's not the drug that they're injecting that's going to cause problems. The thing that usually causes problems for these people is the technique that they use. They don't use the best techniques to inject these drugs. They use very own sterile techniques. So ultimately, that's going to put them in trouble. And also with IV drug users, they can give you a question about an IV drug user for the past few days, having chest pain, shortness of breath, fever, night sweats, maybe a mild week loss. And they tell you that you hear a new murmur. I really hope you're thinking about some kind of endocraditis. Remember, endocraditis is pretty common in IV drug users, especially like triacospid valve endocraditis. So because if you think about it, if you're an IV drug user, IV intravenous, if you're injecting drugs, you're going to be getting it into a vein, veins ultimately drain into the right ear trim. So the first cardiac valve you're going to traverse is the triacospid valve. So these people are very high risk of getting triacospid valve endocraditis on your ex-apps.

And obviously, whenever a person has endocraditis, you're going to be doing blood cultures. Blood cultures are super high. That's always the first thing you do. Whenever a person has endocraditis, and then typically, you're going to do some kind of imaging, like a TEE, transness of a gelatical cardiogram, to look at the vegetation that they have on their valves. And remember, these people that IV drug users, they have a pretty high risk of P Es as well on your exam. And the reason in there is that these people, literally, if you think about it, all those vegetation can disperse and as they disperse, they can begin to occlude pulmonary vessels. I mean, think about it from the triacospid valve. Where's the next point of call for these vegetations? It's going to be your pulmonary arteries. You better believe that one of these vegetations can flick off, I'm going to include a pulmonary artery. They're going to get in big trouble. So those people, all those embolines, those septic embolines can absolutely cause P Es. In fact, if you see this sudden onset, shortness of breath in a person that has a histroventocarditis, one of the first things you need to think about on your test is a PE, especially if the endocarditis is ongoing, especially if the endocarditis is ongoing. Now, what if they give you a question about also a IV drug user? You notice that he has this arm, they tell you that, oh, wow, this person has very significant tenderness of the arm, is very red.

And the person's temperature is like 104. And you can, they say that it's exquisitely tender to a palpation and the patient can barely move that arm. You better believe that the patient has necrotizing fasciitis. If you injecting stuff into your skin, what else do you think is going to happen there? So neck fas can be a question that can easily give you in a IV drug user. Necrotizing fasciitis, again remembering neck fas, you've got a debris. If you don't debris, the person is going to die. That's what's going to happen. So you need to debris. And then you need to give some kind of protein synthesis inhibitor as part of your antibody regimen. So some you're like, cleaned amycin, for example, because many times it's the, it's the toxin that's causing the problem. So you want to give something that inhibits protein synthesis to help, help these people. And then it's also pretty high to know that these individuals that are IV drug users, they can tell you that, oh, this person, you know, for the past few days, we haven't like peripheral edema, foplos pyrinadema, the urine has a weird discoloration. Obviously that's going to be FSGS. That's going to be an FSGS question right there. Remember, focal segmental glomerulus sclerosis is pretty classic in IV drug users. It's something that causes nephrodix syndrome. Remember, in that nephrodix syndrome is T cells that are actually doing the damage. The damage your putocyte food processes and they know this protein leaks out.

Well, if all that protein leaks out, you're going to have a lot of issues with lots of oncotic pressure in your bloodstream. If you don't have adequate amounts of oncotic pressure, then that's not a good thing at all. That's not a good thing at all. You're basically going to be short on protein. And if you're short on protein, then you're not going to be able to keep fluid within your vascular tree. And if you cannot keep fluid within your vascular tree, then you're going to have a lot of fluid extroversition. You're going to have peripheral edema. In fact, this IV drug user theme, I don't know why I'm really lasering it on this right now, but it's just one of these weird things that have become like super important on exams in this day and age. So they may even ask, they can give you a question about this IV drug user and they say, ooh, this person has an increase in the acryctin. This IV drug user already has a disease. The person has an increase in the acryctin. And then they give you like a bunch of arrows, you know, they ask in all this for any and you're tensed and whatever. So what would it look like in these people? Well, think about it. If you're short on protein, there's not going to be enough blood in your vascular tree because, again, there's not enough on caloric pressure. So since blood is not in your vascular tree, it's going to be really hard for you to produce the renal artery.

If you're not profusing the renal artery, you're offering materials, those GG cells will start to freak out. And when they freak out, you're going to release a lot of reining. As you release a lot of reining, you're going to convert into a tensing, a tensing, a tensing, a one and then a single pulmonary capillary. So convert the a tensing and one to a tensing to. And then that a tensing to do a few things is going to go to your zone of glomerulosa of the adrenal cortex going to cause you to release that of our duster is also going to go to your super optic nucleus of your hypothalamus is going to cause you to release a dihydritic hormone. And then a tensing to us. We know it's also a very powerful visual constructor when it acts on its type one receptor on your vascular blood vessels. That's going to cause very powerful visual construction. So what's the thing that kick started all of this stuff? The thing that kick started all of this is a decrease in your effective arterial circulating volume, a decrease in your effective arterial circulating volume. Because again, you did not have oncotic pressures that were adequate in your bloodstream because you were low on protein. So again, I know I just use this issue of FSGS IV drug user. But in any ways they can literally write the exact same question, just a different headline. They can give you an instant liver disease kind of person because we haven't delivered disease.

I don't know, you're not going to be making much of any album in at all. Or they can give you a question about a person that has pusher or if you're a pusher or person, you're not causing enough protein. If you're not causing enough protein, you're going to have a lot of issues with oncotic pressures. Or they can make any kind of nephrodite syndrome question. I mean, FSGS is not only in IV drug users. You can find people that are obese, you can find people that have HIV, you can find people that are African-Americans, people that are Hispanics. There are many different ways they can freeze these questions. And many, many different ways they can freeze these questions. And then for this same IV drug user, what if they give you a question? And they tell you that this person, you know, for the last two days, I mean, having very severe pain in their knees. And you notice that the knee is red, it's warm, it's tender, they have a fever. And they ask you for your next step in diagnosis. Obviously, I would really hope you're like, oh, divine, let's go ahead and go. Do an atrocentesis because this person has septic arthritis. And that septic arthritis probably is going to be from hematogenous spread because this person has been injecting drugs, injecting, injecting, injecting, injecting. Has you injected those drugs? So if he can spread hematogenously to your joints, that can obviously cause septic arthritis.

And whenever a person has septic arthritis, the first thing you always want to do is to go ahead and do an atrocentesis because you're looking for white blood cells and all those things. And obviously, in that case, you're going to treat. So I'll just really encourage you, don't don't sleep on IV drug users, only your exam. I feel like that's a, that's kind of a recipe for disaster. There's a lot of high-yield things they can test. And many times when we have these infections, it's usually from stuff-or else. It's usually a stuff-or else infection. Like when you see them with the tracospid valve endocrinitis, it is very likely going to be stuff-or else. When you see them with septic arthritis, it's usually going to be stuff-or else because sometimes they can make these months specific questions on exams. And then they don't give you much of any hint or anything like that, like G. What am I expected to pick? You want to know that stuff where is this kind of like a big one with these people, with these IV drug users. And even remember, they can even tell you that this person has like pinpoint tenderness on their back. And they have fever and they tell you that when you pop it like a spinoff process or whatever, it hurts like a lot. When you see stuff like that, that's going to be osteomyelitis. That's going to be a spinal osteomyelitis. Again, pretty common in IV drug users on exams. And again, typically it's going to be from stuff-or else.

And again, it's almost certainly going to be from hematoginospread, almost certainly going to be from from hematoginospread. So just going to keep these things in mind on exams. I remember when the person has osteomyelitis, they need to be on many weeks of IV antibiotic therapy. I don't know if whatever bizarre reason, sometimes our friends on the NBM is they'll give you a question about a person that has osteomyelitis. And then they'll say, oh, what is the, you know, you know, these questions when you read and they'll tell you, oh, MRI shows osteomyelitis, bone culture, yeah, yeah, yeah, yeah, yeah, tells you osteomyelitis. So you're like, oh, okay, well, they're giving me everything. Whenever there's the, I have noticed this with the NB Ms, whenever there's these questions where it's like you're reading the question, you're like, oh, I know what this is. And they tell you what it is and everything. Oh, usually the full of questions is like, oh, gee, what's happening here? It's usually kind of a weird, bizarre question that's going to be coming up. So, you know, they can give you this osteomyelitis then. And then they'll say, what's the next best step in pharmacotherapy? And then they'll give you a bunch of drops and you'll see some of them are oral and some of them are IV. Which one should you pick? I really hope you're going to be picking IV formulations of drops. Please do not give oral antibiotics for osteomyelitis on NBM exams.

It's not going to work out well with regards to said, said question. You need to give IV antibiotics because you need very good tissue penetration if a person has osteomyelitis. So, you're not going to be messing around with oral antibiotics. To be honest, with you, again, there is a certain, that's why again, you see, I said this podcast is kind of undefined, but all these things I'm seeing extremely high yield. So, there are certain situations on exams. I guess, let me point them out where you don't want to give people oral therapies. You want to give them a IV therapy. So, let me give you some of the classic ones. So, the first classic one, again, is this IV drug user business with osteomyelitis. If you have osteomyelitis, don't be messing around with an oral antibiotic. Don't get me wrong. And then, osteomyelitis situations, we're like, let's try oral antibiotics, yes. But is that going to be on your test? Probably not. So, you're going to be giving IV antibiotics for osteomyelitis. If a person has many angitis and they have severe symptoms, don't be messing around with oral antibiotics. Don't kill that patient. Go ahead and give them IV antibiotics. And remember, the antibiotics you give for many angiaries, kind of varies, especially when you're treating empirically. It kind of varies based on the age of the people. I mean, if it's a neonate, then you're going to be looking more along the lines of, of several taxing, then called my sena and I'm facilitating.

Because remember, you got to cover a list area. That's why you need to give that an epicylin, because the person is the drug of choice for a list area. And when you have a list area, meningitis, you don't treat it. You don't catch it. The mortality risk is about 100%. It's really bad. So, you're going to give wine, obviously, to cover stuff for us. And then you give sephotoxin to cover the usual gram negative. So, things like my seramine ingestedness, for example, you know, why you go ahead and get that lumber puncture, you know, do some CSF studies and look for the causative organism to help you narrow your antibiotic therapy. So, again, weird stuff like this, pretty high autonome. The remember for meningitis, if the person is like a regular adult, that's on the age 50, and all you really need to do is you can do sephotoxin and vengomaisin. You don't have to throw in an epicylin. But if you're over age 50, you kind of return back to a neonatal land. Instead of just giving a third generation sephotoxin and vengue, you also need to throw in an epicylin. Because, again, this theory is fair, is not uncommon. Let me put it that way. It's not uncommon in people that are over age 50. And again, remember, if you suspect the person has been in jadez, and then it's not showing you a brain MRI, and you notice that, wow, you're seeing parts of the cortex that are next to the midbrain.

They are trying to, and you see a lot of white in those parts of the cortex that are next to the midbrain. They're pretty much telling you that the person has temporal lobeins, sephalitis, or meningitis from herpes. In that case, you're going to give IV cyclover. Whenever a person has herpes meningitis, again, you're not going to be messing around with oral therapy. You're going to give IV cyclover, or they can give you like a CSF study. I see a lot of red blood cells. Remember, herpes love to cause hemorrhagic meningitis and sephalitis. In those circumstances, again, it makes sense to give IV therapy. And also, if a person cannot tolerate, if a person is vomiting, they cannot tolerate oral peel intake. Again, it makes no sense to give them oral antibiotics. In those circumstances, you want to give IV therapy. In general, IV therapy, people put a cannot tolerate peel intake, wait, I'll give them IV therapy. Again, don't forget these things with IV drug users. Honestly, it's not my old, not my game plan, to spend all this time with IV drug users. Again, it's just this weird stuff that they just really love to test on the exams. Again, just do not forget, do not forget stuff, or stuff, or stuff, or with these folks. Again, they can get a lot of skin infections. Think about it, they can get all this cellulitis, just again from injecting, right? Again, with that, on sterile technique, it's probably not a good thing.

And I don't know if whatever bizarre is, and sometimes they also ask, oh, what should a person that has a history of IV drug users be tested for? Again, like I said, you want to test those people for hep C and hep B. But don't forget to actually test these people for a HIV. Don't forget to test these people for a HIV. It's pretty high to know that these people got to be tested for HIV. Because again, many times being a naive drug user has a co-association with just very dangerous behaviors. So these people are pretty high risk of getting a lot of trouble with things like HIV, and getting trouble with things like HIV. And another thing that's also pretty high to know about people that are drug users is that chronic injection of drugs over time. You know, you have this inflammation inflammation inflammation. Because think about it. If you're shooting up your body with things, you think your body is going to receive it well. No, your body is certainly not going to be receiving it well at all. The thing that's going to be happening is you're going to be like, wow, why do I keep getting all these foreign particles coming into me? Why do I keep getting all these foreign particles into me? Why do I keep getting all these foreign particles into me? So over time your body is going to be like, okay, I'm going to keep you in flaming, in flaming, in flaming, in flaming, in flaming, in flaming against these foreign particles. When you inflame, inflame, inflame against foreign particles.

Again, that chronic inflammation is going to lead to the release of some of these acute phase reactants. I'll say probably the most important one is serum amyloid A. Serum amyloid A. What do you think serum amyloid A does? Well, serum amyloid A can congregate and form amyloid. So those people can get systemic amyloidosis. So you start seeing an IV drug user and this person is being developed like a restrictive cardiomyopathy. Their tongue is getting bigger from amyloid deposition. They're going into a reno-failure. Begin to think about amyloidosis in those circumstances. Again, all IV drug users, they love, love, love to test these things on, on exams. And again, don't forget, they can give you a question about an IV drug user and you'll be a female on your exam and they tell you that all this person's breasts or the region just above the breasts are red, they're tender and all those things. Then you want to think about saying the lilies of the breasts because again, they can give you a question. I don't know for every reason. Sometimes you naturally see IV drug users they inject into their breasts. They kind of shoot up their breasts because they've used up many of the veins in their bodies. So they shoot up their breasts and then they can start getting these nasty, nasty, nasty infections. And of course, a wonderful distractor, a friend that the imbi-mi is kind of throwing in there on your testes, they're going to go ahead and throw in mastitis.

But again, it's going to be an IV drug user that was not pregnant, did not recently deliver a baby. It's not breastfeeding at all. They'll put that mastitis and don't pick that. That will not be a good idea. So you want to go ahead and pick up like the person potentially having like cellulitis or again, if the tender that, ooh, the person has like sternal tenderness, sternal tenderness or sternoclavicula joint tenderness, you want to think about osteomyelitis. And the thing is in that case, osteomyelitis may not necessarily be from hematogenos dissemination. It's probably going to be more from like a direct inoculation from a direct inoculation. So again, how does that inoculation happen when you literally just shut up your breasts with a bunch of drops? So again, it's just something you want to keep in mind. So maybe like, oh, divine, how do I know when a person's osteomyelitis is from direct inoculation or is it from hematogenos spread? Many times it's going to be from hematogenos spread. But if you notice that the osteomyelitis is very close to where to an like an entry port, like for example, like, ooh, the person shoots up in their breast and the osteomyelitis around there is probably going to be more direct inoculation. Or you know, like a diabetic, for example, right? The foot ulcers, if the osteomyelitis is almost always going to be from direct inoculation because again, there is like direct access of the bog to those people's bones.

So again, just something want to keep at the back of your mind on one example. So I think I'm going to go ahead and stop here. I mean, the future will see if I have any other thoughts, I believe I do have other thoughts on infectious populations. I'm going to go ahead and address that in the future. So one thing I guess I want to mention before I wrap up, I do have a few classes coming up this month. I may find it to be helpful. I have the bio statistics bootcamp. It's going to be taking place on the 30th of this month as Monday from 5 to 9 p.m. on to it's time. Really, if you're pressing that just struggle, struggle struggles with bio statistics because again, many times these days on exams, it's not, you're not going to be seeing questions or very few of them if any, where it's like just plug and shove into a formula you get the answer. No, they don't really do that much anymore. What do you really do these days is they'll give you a bunch of questions where you don't even have to do much math. It's more like reasoning. So again, if you want to get your reasoning down path solid for bio statistics, this is step one, step three, complex one to complex three. Go ahead and consider the bio stats bootcamp. It's going to be taking place on Monday from 5 to 9 p.m. on to standard time. And then social sciences and ethics, healthcare systems, quality improvement, all these things. It now makes up about 10 to 20 percent of step one, step two, and step three.

So if again, that's something you're interested in. You probably want to consider the five hour social sciences and ethics review. It's going to be taking place this Sunday from 4 to 9 p.m. mountains to standard time on the 29th. All these classes over, if you're interested, just shoot me an email through the website and I'll give you some more information. Okay, so I'm going to go ahead and stop here again. I'll offer one one to you right in front. All the USMEL exams, step one to three, complex one to three, preclinical medical exams, third year clerkship shelf exams. And I help with ER As applications, personal statements, mock interviews. I even help people discuss the aranclus. That's something I've actually done with a lot of people I do it every, a lot from year to year. I've worked with a lot of people that I think will be now residents all over the country. In fact, there are people that I even attendings that I've worked with. And then I have a You Tube channel, Divine Intervention, USMEL broadcasts and videos. That's where I post the videos that I make. And then I also have a new website called Divine Intervention Life Lessons.com. I post two podcasts every week that from a Biblical perspective addresses a life lesson that's pertinent to people. And I have the podcast, actually, on Apple Podcasts, as well as called the Divine Intervention Life Lessons podcast.

And then, you know, the mainstream podcasts also have them on Apple Podcasts and Google Podcasts and Spotify. So thank you for listening to me today. But for the wonderful rest of your day, I'll see you in the next episode. Bye for now.

Tricuspid valve.

Cellulitis or Necrotizing Fasciitis.

Intravenous (IV) antibiotics, due to the need for deep tissue penetration.

Septic emboli; Pulmonary arteries, causing PE.

Systemic Amyloidosis.

Arthrocentesis (joint aspiration).

Hepatitis B (HEPB), Hepatitis C (HEPC), and sometimes Hepatitis A.

Osteomyelitis requires IV antibiotics because deep bone penetration is necessary; cellulitis may be managed with oral agents if mild.

Necrotizing fasciitis, FSGS/Nephrotic Syndrome, and Osteomyelitis.

Pulmonary Embolism (PE) due to septic emboli lodging in the pulmonary arteries.

Intravenous Cyclover; Because of the severity and potential for hemorrhagic complications, IV therapy is required.

Direct inoculation osteomyelitis.

Hepatitis B (HEPB), Hepatitis C (HEPC), and sometimes Hepatitis A.

Osteomyelitis requires IV antibiotics because deep bone penetration is necessary; cellulitis may be managed with oral agents if mild.

Necrotizing fasciitis, FSGS/Nephrotic Syndrome, and Osteomyelitis.

Pulmonary Embolism (PE) due to septic emboli lodging in the pulmonary arteries.

Intravenous Cyclover; Because of the severity and potential for hemorrhagic complications, IV therapy is required.

Direct inoculation osteomyelitis.