DIP Episode 352 - The Clutch Fungi Podcast for Step 2CK/3

Okay, welcome. My name is Divine. This is episode 352 of the Divine Intervention Podcasts. And in this podcast, I'm going to be continuing our Clutch Series. We're going to be doing a Clutch Fongi Podcast. Basically, if you know everything I discuss in this podcast, essentially every question you get on Fongi, at least that's not my goal, in making this podcast you get it right. Again, as a reminder, if you're taking step 2 CK or step 3, or complex level 2 or 3 in December or January, I have two courses next month on the 6th of December, I have an MBA Metastatic and Strategy course, 2 to 430 PM Mountains to Under Time. And then, on from the 7th to the 10th of December, I have a 24 hour review course. It is going to cover internal medicine, peace, surgery, OBGYN, psychneural, communications, ethics, professionalism, bio statistics, multi-system processes and disorders. We're going to cover a ton of that stuff. So, most people have about 130 or so pages worth of notes by the end of the course. So, if you're interested, it should be an email through the website and I'll give you some more details. Okay, so let's just jump right into it. And again, we're going to use Viniets today just to really make this material memorable. And again, they should hopefully be a short podcast. Now, what if they give you a question about a patient that works on a plantation?

And they tell you that over the last three days, he has been having like pain and tenderness along his arm, and arm and form, and he has noticed all these ulcerations. And he also has like prominent, accelerolimphadenopathy. But if you see this, what do you want to think about? I really hope you're saying, oh, divine. Sounds like this person has a spurtricosis. And the spurtricosis is caused by spurtrics, shenkiai. Spurtric shenkiai. It essentially causes a kind of lymphangitis. And remember, lymphangitis, the way it presents on any of these examples, is in a straight line towards the draining lymph node chain, you have significant pain. If, for example, they don't give you a vegetable farmer or anything like that, and they're just giving you like a straight-up lymphangitis question. And you want to think about along the lines of group-based strep. Strep, strep, pyogenesis. One of the most common causes of lymphangitis on an embankment exam. Many times you see red streaks from like a wound or something, and then it will go towards the draining lymph node chain. This person has a problem in the arm. I mean, it like, you know, has a problem in the arm and is going towards the axillary node. So again, classically, this happens in like vegetable farmers or like rose gardeners. People that have sport trickosis. And remember, many times, right, you're pretty by a thorn, you inoculate yourself with the spores.

And in those spores, they go into the presence lymphatic system and begin to cause problems. And how do we treat sport trickosis? Or remember, we treat sport trickosis with itra-conazole. You can use itra-conazole. That's an isole, right? Or you can use potassium iodide. You can use potassium iodide. Well, potassium iodide for the most part, you know, for like cutaneous problems. Now, the next thing I'll talk about, right? So what if they give you a question about a patient that this patient has been on daily prednisone therapy for the last like three months because they have like severe persistent asthma. And then they tell you that for the last five days, they've been having like shortness of breath, productive cough. And that on a chest texture, you see bilateral and testicially infiltrates. If you see that, like bilateral and testicially ground-glass infiltrates. If you see that, what do you want to think about? If you're saying old vines, sounds like this person has neocisties, your vetsinomonia, right? Remember, PCP is a field fungus, believe it or not, it's not a parasite, it's not a bacteria. And remember, I decided to be a little corny today, or I guess, coy, because I threw it in there that always, this is a special chronic steroids. You got to be careful with that on MBM exams. Again, it's not like the MBM is, yes, don't get me wrong, there are new things they test these days.

But again, they're just finding unusual ways to test classic things that they've always tested, right? Because they know that every human being that has the job description met students is like, opch, they must assist in drowitzi, HIV patient, neocistris drowitzi, HIV patient, okay, fine. Well, instead of doing that, how about putting it on a person that has, like, again, chronic immune suppression, right? It can be like a person that has had transplant, right? There's some chronic immune suppression therapy. And then, as my patient, being on chronic therapy for a long time, right? So again, you just got to keep that in mind. And how do we diagnose the most assistive drowitzi? Well, it's actually pretty easy. Actually, it's not very easy. It's technically challenging, but you usually call a pulmonologist of some sort, and they're going to do bronchial viola lavage, and get some sputum samples, right? And those things, staying positive with silver stain. Sometimes the MBM is, if they want to mess around your head, they'll call it methanamine, MET, H-E-N-E-M-I-N-E, methanamine silver stain, right? And how do we treat this? We remember we're going to treat this usually with a comment like back trim, right? We can do it like trimethoprim, so from a foxes all, we can give dapsome, or we can give pentamidine, right? And remember, you, actually, if you're HIV patient, and your city for counts is less than 200, you should be on PCP Prophylaxis.

Again, usually you can do TMPSMX, or you can do pentamidine. And again, I guess the thing I should also mention is when a person has PCP pneumonia, you need to go ahead and, I mean, there are many times those people get steroids at the same time, right? Because if they appear on the criteria, certain criteria that makes you say, okay, let's throw in some steroid. Usually the criteria that gets you there is when the P little AO2, right? So your arterial oxygenation is less than 70, or your A ingredient is 35 or more. In those circumstances, you're going to go ahead and put those people on steroids, right? And the inflammatory action from treating that infection can cause some pretty, pretty significant problems, right? So those are the key things I would say you should keep at the back of your mind with regards to PCP pneumonia, right? And again, what if they tell you that, you know, the patient has PCP pneumonia, they are presenting a unit that, wow, those person sodium is like 125, like some low value. If you see that, you know, I really, really, really want you to think about SID, right? This is your Vetsin pneumonia is associated with SID each, right? Remember, in SID each, you're going to be reabsorbing the ton of water from your urine. So that's going to dilute your serum. So you're going to get hyponytremia, right? But your urine is going to be very hypertonic, right? It's going to have a very high specific gravity, you know, greater than 1.

It'll be really high, greater than 1.01 to, right? On an in-beam exam. And then what if they tell you that, you know, the patient is started on tri-metalline from sulfur monthoxysol therapy? And then you notice that, wow, these people start having like perioreal cyanosis, you notice that the ahimoglobin, let's say the baseline was like 13, now it's like 8. And then the pressure has an un-conjugated hyperbular banymia. Well, if you see that, I hope you're saying, oh, divine. Sounds like this person has G6 PD deficiency, right? Because again, the thing is, the sulfur drugs are very powerful oxidizing agents, right? So if you're a person that cannot make, you have a problem with a glucose 6-phosphatide hydrogenase, then you'll be able to make NADPH, right? So your glutathione will not be replenished. So you're going to run into a problem, so G6 PD deficiency, right? And remember, for those people, we're going to see high-ends bodies and bite cells on a blood smear, right? Now, what if they give you a question and about an obese female, you know, a BMS like 40? And then they tell you that, you know, she has this right itchy rash under her breast. Well, if you see this, this is easy, right? What is that? I mean, that's that's in in tetragome, right? So it first has in tetragome. Right? Remember, in tetragome, classically, it's caused by Candida. Candida is one of these very high-value bugs for the USML exams. It's a very high-value fungus.

This is one of those things that you know that you're taking a USML exam. You're likely going to see some kind of Candida question, right? So Candida causes many different kinds of problems, right? So I'm just going to cut love them for you right now, right? So again, they can give you an obese person, right? You know, it can be a person that has been on antibiotics or prison has diabetes. The way I think about it, the person has diabetes is almost like their body is very sweet for bacteria. Or, you know, fungi is in this case, Candida, right? So that's in tetragome, INTR, TRIG, or in tetragome, right? Or they can give you a HIV patient, right? That has or dynophasia or dysphysia, right? That's going to be pretty classic for, you know, Candida is so fragile. So remember Candida is the most common cause. That's very high. There's the most common cause of a sophagitis in HIV patients, right? And again, remember typically we're going to treat that with like an isol of some sort. You can use like an oral isol or you can use my statins, which are sualo, or you can even use like an isol like cough drop, right? Like they're called like isol those engines, right? Those are things you can use on MDM exams, right? And again, remember, friends at the MDM is it doesn't always have to be HIV patients that have Candida list of a gyitis. They can give it to a person that has asthma that is on like chronic like steroid inhalers, right?

Again, those steroids are powerful immunosuppressants that can cause Candida list of a gyitis. Or they can give it to a person that has, you know, that may be on oral steroids chronically or a person that has diabetes, right? Again, many times it's the disease you find if you would have immunocompromised, believe it or not, you can find it in diabetes. Diabetes compromises your immune system, right? That's why the diabetes is bad, right? Remember, they can give you like a young sexually active person that again has this vaginal discharge, right? And the pH is 4.5 or lower. So the pH is 4.5, that's included, 4.5 or lower, right? And or you can be a person that's a diabetic or recently two antibiotics. To be honest with you, I kind of think of this as almost like CD for the vagina, believe it or not. And this person, you know, obviously has Candidal vovovaginitis, right? Remember in Candida, right, when you do like the white prep, you're going to see pseudo-hifi, right? So do hyphen. And for the most part, again, these people respond very beautifully to some kind of topical isle. Well, in kids, remember they can get a diaper rash. Many times you'll be those red lesions and you'll see some satellite lesions, right? So you see lesions kind of spread all over the place. Again, a topical isle is pretty much what you need in those circumstances, right? And again, remember, people that have people that are very, you know, immunocompromised, they say they're like super neutropinic.

So people like on chemotherapy or people that are on transplant, immunosuppressants, right, they can get the seminarytheta Candiditis, right? They can get the seminarytheta Candiditis, right? And whenever a person has the seminarytheta Candiditis, remember, you're not going to be using an isle in those circumstances. No, that's ridiculous, right? The things you're going to be using on NBM exams, you can try something like an photoresym B, right? It's very good for the seminarytheta Candidial infections. Or you can try on a kind of kindin, right? A kind of kindin. The thing is, these are kind of Candidians, they are like the cell wall synthesis inhibitors in fungal world, right? They inhibit an enzyme called 13-beta-D-glucan synthase. I'll say that again. 1,3-beta-D-glucan synthase. It's an enzyme that helps you make the cell wall in fungi, right? So a kind of kindin that drops like, Caspo-fongin, mica-fongin, and anibula-fongin. So again, that's how you can treat systemic fungal, a systemic candidala infection. Now, what if they give you a question about a patient? They tell you that this patient has a history of TB. That was successfully resolved with ripe therapy, I'm not sure if it's B6. And then they tell you that for the last two weeks, this person has been having like night sweats, weight loss, hemoptysis, and then they give you some labs. And you notice that, wow, you get the CBC. And you notice that the white count is elevated and the ocino feels like 20%.

If you see that, what do you want to think about? I really hope you're saying, oh, divine. This person has an aspergilloma, right? Aspergilloma. Remember, these aspergillomas, they love to inhabit old TB cavities. Old TB cavities. And many times you need to do a biopsy of those stains and then you surgically remove them. For the most part, people that have aspergillomas, they don't really need antibiotic therapy on endemic symptoms. So what are some other ways they can test aspergillos? Remember, if you're looking at it under the microscope, you're going to find these acute angle branching high feet, like these, they're septate, right? S-E-P-T-A-T-E. They're septate high feet, they branch at 45 degree angles. And again, the thing is, whenever you have any disorder that involves your neutral fills not working well, you're going to get a lot of problems with aspergillos. Aspergillos, believe it or not, happens to be a catalys positive opening. So you can already begin to see how they can give like a boy. They tell you it has all these abscesses, has these recurrent aspergillos infections. That's going to be CGD. Remember in CGD is the neutral fills that are really getting potent. And don't forget, CGD is a deficiency of what? Of any DPH oxidies. So again, you cannot make reactive oxygen species. So again, all these catalys positive organisms like Candida, aspergillos, Serisha, Marcesens, Staphoreus. They're going to do a number on that person.

So those are big things to know about aspergillos. And don't forget aspergillos, how do we treat it? Aspergillos when a person has like disseminated aspergillosis. When a person has disseminated aspergillosis, you want to put them on like a... For a connozzol, or a posa connozzol. For a connozzol, or posa connozzol. Those are your first line agents. Your second line agents are going to be more along the lines of an amphoteric C&B. So again, there are many different ways they can test aspergillosis on your exam. I mean, they can even tell you a person that has like really bad asthma, a person has been on beta-2-agannas, they don't seem to be getting better. And then they tell you that, oh, chest X-ray shows like bronchiectasis, like trum tracking. And then they can even tell the person has a history of cystic fibrosis. And they have like very big tiny ocinophilia. If you see something like this, right? This is ABPA, right? Allergic bronchopomonari aspergillosis. It responds beautifully to sterile. So it will be a person that has like really hard to treat asthma. And just notice that boy, these people's ocinophilic counts, they are IgE's just through the roof. If you see stuff like that, I want you to think about aspergillus, right? And then they tell you about a person that, you know, consumes a ton of mushrooms, and then they have hepatocellular carcinoma. Then you want to think about aflatoxins.

Remember, there are certain species of aspergillus that actually have the ability to make aflatoxins. Those aflatoxins are very potent carcinogens. They can absolutely positively cause hepatocellular carcinoma. And don't forget, what's the tumor marker for hepatocellular carcinoma? Hope you're saying it all divine. It's aflatoxinoprotin, right? Aflatoxinoprotin. Remember, AFP is the tumor marker for hepatocellular carcinoma. It's the tumor marker for, oh, come on, the vine, think. It's the tumor marker for a yolk sac tumor. Remember, sometimes they call those things endodermal sinus tumors. And it's also the tumor marker for hepatoblastomas. Remember, hepatoblastomas are those benign liver masses that we find in kids that have beck with widermin syndrome, right? So those are the three high-old malignancies that you could see on your exam or masses that have aflatoxinoprotin as a tumor marker, right? Now, what if they give you a question about a patient that lives in Arizona? So HIV patient has had really bad meningitis for the last, you know, has like, you know, no corrigidity, headache, fever, blah, blah, blah, blah. If you see that, right, what do you want to think about? I'll hope you're saying, oh, divine. This is cryptococosis, right? This person has infection with cryptococococinial formans, right? Cryptocococococinial formans. Remember, most times, and you know, it's not just enough to know that it's crypto.

Remember, cryptococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococ And that number puncture, you can either do like the latex particle like gluteination or you can consider using the India ink stain, right? You can use the India ink stain, right? And because this is a fungal cause of meningitis, well, what should be true of your CSF opening pressures? Your CSF opening pressures are going to be really high, right? And you're going to see an abundance of white blood cells, what's going to be lymphocytes, right? It's going to be lymphocytes and your glucose is going to be low. That's a nice way to differentiate that from a bacterial meningitis where everything is the same like, you know, the LVS CSF opening pressures, high white count, low glucose, but in bacterial meningitis, it's your neutrophils that are high. But in fungal meningitis like from crypto, for example, your lymphocytes and the things that are going to be increased. And how do we treat our crypto cocosis? We remember a tricky crypto cocosis with amphotericin B and flu cytosin, right?

amphotericin B and flu cytosin amphotericin B and flu cytosin. And then after you treat those people, you need to put them on flu connozzol, right? For like nine to 12 months to reduce the risk of a recurrence. Now, what if they give you a question about a patient? They tell you that this patient has been on chemotherapy. And then for the last three days, this patient has been having like really bad headache, really high fevers, having a happy staxis. So blood is coming out from the patient's nose, has a lot of facial pain. And they tell you that you see this necrotic ulcer on the patient's face. If you see this, what are you thinking about? Again, if I want that to be very nice to everyone, listen to this podcast, I'll say, oh, this is a diabetic in DKA, right? But again, you need to know a wide variety of scenarios that could pop up on you exams, right? So again, the classic patient for this, the sort I'm going to discuss now, is a diabetic patient in DKA, but a very nice fancy way of friends that the MB Ms could test this is it can be a person that is immunocompromised, right? If you see all these things together, this is mucomicosis, right? This person has mucomicosis many times. Don't forget that this is caused by a rhizopost species, right? Rhizopost, rhizopost, rhizopost. And how do we treat this? Well, there's not many options here. I mean, this is a surgical emergency.

You need to first of start by deep breathing the person's face, and then you're going to give the person a photoresym B, right? You deep breathe, give them a photoresym B, and they improve very, very hard for a good outcome. And then, as I begin to wrap up, I think I should talk about the TMS, right? So the TMS, TMS, TMS, right? Again, many people have seen so many people get the stuff wrong on MBM exams. I don't really get why. Pretty straightforward, right? You'll be a person that, again, has like a skin lesion, you know, as central clearing has raised edges, right? It's going to be tinium. It's just these cutinios, you know, demodolfite, a fungal infections, right? Now, what is the most common cause of tinium? It's going to be tricophytein, right? T-R-I-C-H-O-P-H-Y-T-O-N. Tricophytein is the most common cause. It has very high autonome. The second most common cause is microsporum. M-I-C-R-O-S-P-O-R-U-M, microsporum. And then the third most common cause is a buck called epidermal fighting, epidermal fighting, P-I-D-E-R-M-O-P-H-Y-T-O-N, right? Those are the bugs in order. The T first, the M second, the E third. I promise you, our friends at the MBM is right questions when you put all these bugs as answers. And then you have to pick the most common, which will be tricophytein. You can just pick any tricophytein species, tricophytein tonsurans, tricophytein rubrum, whatever. Tricophytein is the most common cause. That's very high autonome.

It's the most common cause of tinias, right? Again, tinias are basically like rainworm, right? Tinium copper is at least, right? So how do we treat these infections? Remember, you're going to treat it with a topical isle, right? Topical isle, topical anti-flungle works great for these problems. But if the person has certain kinds of tinia, especially like onychomaicosis, it involves the nails or tinia capetes, it involves the head, right? Then in those circumstances, you need to use systemic therapy, right? You need to use drugs like oral grizzio-fulvin or oral-tribinaphym, where you can only use topical therapy in those cases. You need to use oral grizzio-fulvin or oral-tribinaphym. And again, nice way of friends at the MBM is can integrate this grizzio-fulvin is a person that gets pregnant, right? And they are no C Ps, but they are taking grizzio-fulvin for some tinia infection, right? Again, remember grizzio-fulvin can rev up cytochromp 450, so it's going to increase the metabolism of that oral contraceptive pill. If that happens, you're going to get pregnant, right? So don't forget your cytochromp 450 inducers, right? You'll see p450 inducers, right? Grizzio-fulvin, problemazepine, phenetoin, mabutary, triphanpan, right? St. John's warts, those are the key, key big ones. You kind of need to know for purposes of your test.

And I guess since we're talking about tinians, it may not be the worst idea, you know, what if they tell you that you see some person in the summer, you know, they have these lesions on, it's almost like around like in a shell like distribution, right? They have these hyper and hypopigmented lesions on the skin, right? And they tell you that, you know, it's a little bit itchy and the person like uses swimming pools or whatever, right? This is easy, right? This is tinia vesicolo, right? Sometimes the micoli-pitariasis vesicolo, right? Vercicolo is spelled V-E-R-S-I-C-O-L-R, right? Vercicolo. Now, what is the bug that causes this? So remember, this is gonna be caused by malacisia fervor. Malacisia, I believe it's spelled N-A-L-A, double S, E-Z-I-A, and then fervor is like fervor, like F-U-R, twix, F-U-R, F-U-R, right? So malacisia fervor, and then again, if you do like a, like a, you look at this stuff under the microscope on prep, you're gonna see the spaghetti and meatballs pattern, right? That's something that they love to test on exams. So I guess some of you may be like, ah, divine, why do they have these hypopegmented lesions on the skin? Well, if you think about it, the thing is malacisia fervor, one thing it does is it actually breaks down, it actually breaks down lipids, and those lipids, it breaks down, you know, because remember lipids contain fatty acids. Some of those fatty acids actually have the ability to inactivate an enzyme called tyrosinase, right?

So where do you know tyrosinase from? Okay, well, let's talk about this. Let's do a little biochemistry. Well, if you think about it, remember that, phenylalanine is converted to tyrosine. By this enzyme we call phenylalanine hydroxylase, right? Remember that uses tetrahydrobiobtery as a cofactor, right? To remember, whenever your phenylalanine hydroxylase doesn't work well, that's how people get picky in the first place, right? So let's keep going. So, and then that tyrosine is converted in some steps by tyrosinase to melanin, right? So if you inactivate tyrosinase, then you're not gonna be making melanin. So you're gonna have skin, hypopegmentation. That's why they have those lesions in people that have tiniest vesicular. Another way they can integrate this, again, we know that PKU, right? phenyl ketonuria, many times these people are gonna have mousey-mustiodeur, and they're gonna have like albinism. The mechanism behind that albinism is just a more upstream problem. Is again, they don't have phenylalanine hydroxylase. So they don't even make tyrosin in the first place, right? So you don't have any feedstock for melanin production. So they're gonna run into trouble. Again, these are just ways they love, love, love to integrate things on exams, right? And again, you will see for those that attend the 24 hour course next month, this is essentially how I love going through material, right?

Just integration, integration, integration, because again, that's the thing that will ultimately help you on the US NL Es, right? Instead of like some random, oh, let's do a lecture on this drop. Let's do a lecture on that. No, no, no, no, no, no, no, no, no, no, no, no, no, no, just the ability to see things in multiple dimensions. It just makes you dispatch your NV Me questions very quickly and very accurately, right? And then I guess to wrap up here, because this podcast is beginning to go along, right? Don't forget your geographical fungi. I love to call them geographical fungi, right? So you see a person from Kentucky or Ohio, and this person has an intestinal pneumonia, right? And unless they went spalonkin, right? They went like cave exploring, or they played with like, you know, bird or, you know, animal poop of some sort, and the living Kentucky or Ohio or Indiana, those parts of the country. One thing about histoplasmosis, right? HISTO Plasmosis, for the most part, you're gonna treat it with itra-conazole, right? You're gonna treat it with itra-conazole. And again, the way you actually diagnose histone is you can do like a urinary or serum antigen to make the diagnosis. And don't forget, if you leave in the susceptible part of the country, you have HIV. So let's say, for example, you live in Kentucky or Ohio or Indiana, whatever, and your city for count is less than 150, and you have HIV, you need to be placed on intraconazole for histoplasmosis per relaxes, right?

The analogous bog, if you live in the southwestern United States, so like Arizona, Nevada, Texas, California, New Mexico, El Paso, you know, stop places like that. And you have HIV and your city for count is less than 250, you know, thinking about along the lines of coxidiumicosis, right? Coxidiumicosis, coxidiumicosis. Remember, it has that association with the south, western United States. And don't forget, coxidiumicosis, they can give it as a question that, you know, when people have like pulmonary infection after some kind of earthquake, right? Because again, that's where they call it valley fever, right? It loves to, it stays in the ground, and you know, it's almost like it's on Earth it, when you have a disturbance of geography, right? So like an earthquake or a volcano or stuff like that, those are all associations they can give on the exam. And remember, coxidiumicosis, again, like I said, if you have HIV, you live in the susceptible region of the country, when your city for count is less than 250, you need to be placed on intraconazoleus profile axis. When it just so happens that intraconazole is also the way we trick coxidiumicosis. And don't forget, coxidiumicosis has something in common with stracoidosis, what is it? What is that dermatologic finding? I hope you're saying, oh, divine, everything I know, do so, right? So that painful stracula lesion read on the lower extremities, right? That's gonna be a rhythmanoidosum.

We find that has an association with coxidiumicosis. You know, if they give you a question about like Michigan, like that Michigan area or like Ontario, like in Canada, and you see this person, they have like severe bone pain, they have these lesions on their skin, that sometimes they look like cancer, right? They wanna, and they tell you that, oh, they do like microscopic studies, and they see like broad-based body yeast, this is easy, right? This person has blasto-micosis. Remember blasto-micosis again, also response to intraconozal, but again, blasto, the key key way to know that, oh, I'm dealing with blasto again, geography, Michigan, Ontario. There's also skin lesions, right? And there's also bone problems, bone. And then don't forget your triple-b's, right? Broad-based body needs, right? Your broad-based body needs, right? Those are things you think about. And again, histoblastocoxy, all these things respond beautifully, beautifully to intraconozal. So I think I'm gonna go ahead and stop here. Again, as I mentioned, that it be in the podcast again, if you're interested, the Stetusiki Step 3 course, should be an email through the website, and the NV Me Testicking Strategy Scores as well, should be an email through the website. And then I do offer one or one tutor in for all the USMLA exams, right? Step 1, Step 2 CK, Step 3, pre-clinical medical exams, 30-ish-off exams, complex level one, two, and three, I tutor for all those exams.

The only thing I don't tutor for is OEMN, but pretty much every other thing I tutor for. And then if you need help with your ERAS application, like more interviews on all those things, I do all those things with people. I've worked with tons of people that are now residents at very established programs in many different residency programs around the country. So if you're interested, again, just shoot me an email. And then I have these podcasts on Apple podcasts, some Google podcasts on Spotify, at least the most recent 150. If you want everything from episode one, all the way to episode three, 52, you need to go on the website itself. Actually, if you're subscribed to the website, divineinterventionpodcast.com. When I make a new podcast, you get an email notification. And then I also have a You Tube channel, Divine Intervention, USMLA podcast and videos. Subscribe to that, that's where I post the videos that I make. I've made some videos in recent times that I actually posted on there. And then finally, many people say, oh, Divine, I really love your life lessons podcasts. So I started a new website called Divine Intervention, Life Lessons.com. Basically, I put a very short podcast on just key life lessons, things that are very relevant to humanity, essentially, have like 39 podcasts right now. I'm gonna be adding roughly to every week, except some kind of emergency arises. And again, many people have used that website as well and they find it to be helpful.

Actually, if you go on Apple podcasts, you're gonna find the podcast there as well. It's called the Divine Intervention Life Lessons Podcast. I've had many good ones, a pretty popular one is like the one on marriage and things like that. Again, if you're interested in any of those things, just check them out. They're all free, free available. There's no charge. You don't even have to sign up for anything. Even for the websites, actually, you don't have to sign up for anything. The only benefit you get from a sign up is if I make a new podcast, you get an email notification. And again, any little bit of support helps for sure, right? So thank you for listening today. I encourage you keep up hope. If you're in that tough situation where you feel like, well, there's no way out. I just wanna tell you that God loves you. You're a great person. Even if you're going through a temporary, even if you're going through a big problem right now, just remember that every problem has some kind of an expired deed, right? There's no problem that lasts forever, right? Every problem has an expired deed, right? So just remember God loves you. Remember you are loved, right? Remember you are precious. You're not a waste. It doesn't matter what your background is, right? Like, it doesn't matter what home you're from, it doesn't matter what country you're from. It literally doesn't matter, right? God has a plan for your life. There are many wonderful things about your future, right?

So don't throw in the towel. Don't give up hope. Keep hope in life. Everything will be well. I mean, I love this verse of the Bible that says, we know that all things work together for the good of them that love God and are called according to His purpose, right? But just remember Jesus loves you. God loves you. You're loved. Even if your family has rejected you or thrown you away or whatever, or people are mocking you, just remember that Jesus loves you, right? You're a great person. I love the Bible. The Bible says that you're fearfully and wonderfully made, right? You don't worry about people that say, oh, you're ugly. You look nasty, whatever. Doesn't matter. No, you're fearfully and wonderfully made. Remember life many times. It's about perspective, right? Perspective. So don't waste your time on things that make you see life the wrong way. Rather spend your time, invest your time in things that make you see life the right way, right? So just remember these words as you go through your day and I wish you all the best. So until next time, have a wonderful day. God bless you. Thank you.

Lymphangitis (sporotrichoid pattern)—painful, linear streaks extending along lymphatics from the inoculation site.

Candida species. It is a common opportunistic pathogen associated with immunosuppression and hyperglycemia.

High opening pressure, lymphocytic pleocytosis, and low glucose. (Differentiates from bacterial meningitis which has neutrophilic predominance).

Aspergillus species. These organisms often colonize necrotic tissue within former TB sites, leading to aspergillomas.

1. Trichophyton (most common); 2. Microsporum; 3. Epidermophyton.

"Spaghetti and meatballs" pattern, caused by Malassezia furfur.

Inactivation of tyrosinase. Malassezia breaks down lipids, which inactivates the enzyme needed for melanin production.

Voriconazole or Posaconazole (Azole antifungals).

Diabetes, chronic steroid use/immunosuppression, and antibiotic use.

Alpha-fetoprotein (AFP).

Histoplasmosis (Histoplasma capsulatum).

Geography: Michigan/Ontario area. Microscopy: Broad-based budding yeast.

Echinocandins (e.g., Caspofungin).

Phenytoin, Carbamazepine, and St. John's Wort.

Voriconazole or Posaconazole (Azole antifungals).

Diabetes, chronic steroid use/immunosuppression, and antibiotic use.

Alpha-fetoprotein (AFP).

Histoplasmosis (Histoplasma capsulatum).

Geography: Michigan/Ontario area. Microscopy: Broad-based budding yeast.

Echinocandins (e.g., Caspofungin).

Phenytoin, Carbamazepine, and St. John's Wort.