{"version":"1.0.0","segments":[{"startTime":0.891,"endTime":3.19,"body":"[upbeat intro music]"},{"startTime":3.19,"endTime":5.6,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.19,"endTime":5.6,"body":"to Harrison's Podclass,"},{"startTime":5.6,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.6,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.88,"body":"I'm Cathy Handy."},{"startTime":9.88,"endTime":11.733,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.88,"endTime":11.733,"body":"Wiener, and we're coming to you"},{"startTime":11.733,"endTime":14.083,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.83,"endTime":17.903,"body":"[Dr. Handy] Welcome to episode 64,"},{"startTime":17.903,"endTime":20.73,"body":"a 20-year-old with fatigue and fever."},{"startTime":20.73,"endTime":22.218,"body":"[Dr. Wiener] A 20-year-old"},{"startTime":20.73,"endTime":22.218,"body":"man presents with"},{"startTime":22.218,"endTime":25.67,"body":"four weeks of fatigue, fever,"},{"startTime":22.218,"endTime":25.67,"body":"headaches, and myalgias."},{"startTime":25.67,"endTime":28.43,"body":"He was previously seen in"},{"startTime":25.67,"endTime":28.43,"body":"urgent care for these symptoms"},{"startTime":28.43,"endTime":30.55,"body":"and was prescribed a course of antibiotics"},{"startTime":30.55,"endTime":33.17,"body":"after ruling out COVID-19 infection."},{"startTime":33.17,"endTime":35.79,"body":"He returns today after"},{"startTime":33.17,"endTime":35.79,"body":"completing his antibiotics"},{"startTime":35.79,"endTime":37.88,"body":"reporting that his"},{"startTime":35.79,"endTime":37.88,"body":"symptoms have persisted,"},{"startTime":37.88,"endTime":39.57,"body":"and now he has notable throat pain"},{"startTime":39.57,"endTime":41.61,"body":"on trying to swallow solids or liquids,"},{"startTime":41.61,"endTime":43.93,"body":"as well as a rash on his trunk."},{"startTime":43.93,"endTime":45.22,"body":"The symptoms have led him to take"},{"startTime":45.22,"endTime":47.78,"body":"a leave of absence from"},{"startTime":45.22,"endTime":47.78,"body":"his college courses."},{"startTime":47.78,"endTime":49.94,"body":"[Dr. Handy] So what we have"},{"startTime":47.78,"endTime":49.94,"body":"so far is the young man"},{"startTime":49.94,"endTime":53.31,"body":"who's been ill for about a"},{"startTime":49.94,"endTime":53.31,"body":"month based on the time course."},{"startTime":53.31,"endTime":55.0,"body":"He tried a course of antibiotics"},{"startTime":55.0,"endTime":57.41,"body":"and it didn't have any"},{"startTime":55.0,"endTime":57.41,"body":"clinical improvement."},{"startTime":57.41,"endTime":59.96,"body":"Initially because of that, I"},{"startTime":57.41,"endTime":59.96,"body":"think it's reasonable to think"},{"startTime":59.96,"endTime":62.21,"body":"that this might be a"},{"startTime":59.96,"endTime":62.21,"body":"common viral syndrome,"},{"startTime":62.21,"endTime":65.37,"body":"but you would expect the symptoms"},{"startTime":62.21,"endTime":65.37,"body":"to resolve at this point."},{"startTime":65.37,"endTime":68.2,"body":"Now I'm not sure exactly"},{"startTime":65.37,"endTime":68.2,"body":"what antibiotic he received,"},{"startTime":68.2,"endTime":70.58,"body":"but without any response,"},{"startTime":68.2,"endTime":70.58,"body":"you have to think"},{"startTime":70.58,"endTime":73.2,"body":"that this is either"},{"startTime":70.58,"endTime":73.2,"body":"non-infectious in etiology,"},{"startTime":73.2,"endTime":76.07,"body":"potentially oncologic,"},{"startTime":73.2,"endTime":76.07,"body":"or would be a less common"},{"startTime":76.07,"endTime":77.74,"body":"infectious etiology or something"},{"startTime":77.74,"endTime":79.75,"body":"not covered by the antibiotics."},{"startTime":79.75,"endTime":81.14,"body":"Can you tell me more about his medical"},{"startTime":81.14,"endTime":83.5,"body":"and social history before an exam?"},{"startTime":83.5,"endTime":85.542,"body":"[Dr. Wiener] Okay, sure."},{"startTime":83.5,"endTime":85.542,"body":"He's a college student"},{"startTime":85.542,"endTime":87.88,"body":"and lives in a large metropolitan city."},{"startTime":87.88,"endTime":91.165,"body":"He has no past medical"},{"startTime":87.88,"endTime":91.165,"body":"history, takes no medications,"},{"startTime":91.165,"endTime":94.28,"body":"he grew up in the suburbs"},{"startTime":91.165,"endTime":94.28,"body":"and has had no recent travel."},{"startTime":94.28,"endTime":96.67,"body":"He's up-to-date with all his vaccinations."},{"startTime":96.67,"endTime":98.73,"body":"There is no family history of cancers."},{"startTime":98.73,"endTime":101.936,"body":"He does admit a vigorous and"},{"startTime":98.73,"endTime":101.936,"body":"diverse sexual life with men"},{"startTime":101.936,"endTime":104.04,"body":"and women, typically characterized by"},{"startTime":104.04,"endTime":107.52,"body":"unprotected oral, vaginal, and anal sex."},{"startTime":107.52,"endTime":108.61,"body":"[Dr. Handy] Well, based on that,"},{"startTime":108.61,"endTime":111.34,"body":"living in a college dorm"},{"startTime":108.61,"endTime":111.34,"body":"and his sexual history"},{"startTime":111.34,"endTime":114.22,"body":"would put him at risk for"},{"startTime":111.34,"endTime":114.22,"body":"a number of infections."},{"startTime":114.22,"endTime":116.65,"body":"Tell me about his physical examination."},{"startTime":116.65,"endTime":118.575,"body":"[Dr. Wiener] Okay, his"},{"startTime":116.65,"endTime":118.575,"body":"vital signs are notable for"},{"startTime":118.575,"endTime":121.97,"body":"a temperature of 38.5"},{"startTime":118.575,"endTime":121.97,"body":"Celsius, heart rate of 105,"},{"startTime":121.97,"endTime":124.4,"body":"blood pressure of 110 over 65,"},{"startTime":124.4,"endTime":129.264,"body":"a respiratory rate of 18 and"},{"startTime":124.4,"endTime":129.264,"body":"a room air saturation of 97%."},{"startTime":129.264,"endTime":131.8,"body":"His oral exam is notable"},{"startTime":129.264,"endTime":131.8,"body":"for a diffusely red"},{"startTime":131.8,"endTime":134.31,"body":"and tender pharynx with"},{"startTime":131.8,"endTime":134.31,"body":"multiple white plaques"},{"startTime":134.31,"endTime":137.48,"body":"on the soft palate and"},{"startTime":134.31,"endTime":137.48,"body":"on the posterior pharynx."},{"startTime":137.48,"endTime":140.06,"body":"His tonsils seem diffusely enlarged."},{"startTime":140.06,"endTime":143.86,"body":"He has bilateral anterior"},{"startTime":140.06,"endTime":143.86,"body":"and posterior lymphadenopathy"},{"startTime":143.86,"endTime":147.04,"body":"with the largest nodes about"},{"startTime":143.86,"endTime":147.04,"body":"two centimeters in diameter."},{"startTime":147.04,"endTime":150.15,"body":"His lungs, heart,"},{"startTime":147.04,"endTime":150.15,"body":"abdominal exam are normal."},{"startTime":150.15,"endTime":152.06,"body":"His spleen is not palpable,"},{"startTime":152.06,"endTime":154.74,"body":"but he does have a"},{"startTime":152.06,"endTime":154.74,"body":"diffuse maculopapular rash"},{"startTime":154.74,"endTime":157.05,"body":"on his thorax and on his back."},{"startTime":157.05,"endTime":159.495,"body":"[Dr. Handy] Well, based on"},{"startTime":157.05,"endTime":159.495,"body":"what you told me with the rash,"},{"startTime":159.495,"endTime":162.92,"body":"the lymphadenopathy, the"},{"startTime":159.495,"endTime":162.92,"body":"oral exam, his vitals"},{"startTime":162.92,"endTime":165.643,"body":"and the social history,"},{"startTime":162.92,"endTime":165.643,"body":"acute HIV has to be high"},{"startTime":165.643,"endTime":167.571,"body":"on the differential diagnosis."},{"startTime":167.571,"endTime":169.36,"body":"[Dr. Wiener] Tell me more about acute HIV."},{"startTime":169.36,"endTime":172.62,"body":"[Dr. Handy] It's estimated that"},{"startTime":169.36,"endTime":172.62,"body":"about 50 to 70% of individuals"},{"startTime":172.62,"endTime":174.69,"body":"with HIV infection will experience"},{"startTime":174.69,"endTime":176.17,"body":"an acute clinical syndrome,"},{"startTime":176.17,"endTime":179.59,"body":"that's about three to six weeks"},{"startTime":176.17,"endTime":179.59,"body":"after the primary infection."},{"startTime":179.59,"endTime":182.37,"body":"And the period of acute"},{"startTime":179.59,"endTime":182.37,"body":"viremia and the syndrome"},{"startTime":182.37,"endTime":184.91,"body":"can present similarly to"},{"startTime":182.37,"endTime":184.91,"body":"other viral illnesses,"},{"startTime":184.91,"endTime":186.7,"body":"such as mono, for example."},{"startTime":186.7,"endTime":188.61,"body":"His presentation would be pretty typical"},{"startTime":188.61,"endTime":189.76,"body":"and that includes thrush,"},{"startTime":189.76,"endTime":192.33,"body":"which it sounds like"},{"startTime":189.76,"endTime":192.33,"body":"he might have on exam."},{"startTime":192.33,"endTime":194.985,"body":"Thrush appears as a white,"},{"startTime":192.33,"endTime":194.985,"body":"cheesy exudate often on"},{"startTime":194.985,"endTime":198.06,"body":"an erythematous mucosa in"},{"startTime":194.985,"endTime":198.06,"body":"the posterior oropharynx."},{"startTime":198.06,"endTime":200.43,"body":"And while most commonly"},{"startTime":198.06,"endTime":200.43,"body":"seen on the soft palate,"},{"startTime":200.43,"endTime":203.73,"body":"early lesions are often found"},{"startTime":200.43,"endTime":203.73,"body":"along the gingival border."},{"startTime":203.73,"endTime":206.62,"body":"You can make the definitive"},{"startTime":203.73,"endTime":206.62,"body":"diagnosis by direct examination"},{"startTime":206.62,"endTime":209.0,"body":"of a scraping for pseudohyphal elements."},{"startTime":209.0,"endTime":211.54,"body":"The maculopapular rash"},{"startTime":209.0,"endTime":211.54,"body":"is also pretty common"},{"startTime":211.54,"endTime":213.13,"body":"and is non-specific."},{"startTime":213.13,"endTime":215.0,"body":"It looks like the maculopapular rash"},{"startTime":215.0,"endTime":216.89,"body":"of many acute viral syndromes."},{"startTime":216.89,"endTime":218.93,"body":"But patients may also get acute bronchitis"},{"startTime":218.93,"endTime":221.69,"body":"and sinusitis with acute HIV infection."},{"startTime":221.69,"endTime":223.426,"body":"[Dr. Wiener] So, based"},{"startTime":221.69,"endTime":223.426,"body":"on what you've said,"},{"startTime":223.426,"endTime":226.57,"body":"you have a high index of"},{"startTime":223.426,"endTime":226.57,"body":"suspicion for acute HIV."},{"startTime":226.57,"endTime":228.76,"body":"And in this case, the"},{"startTime":226.57,"endTime":228.76,"body":"history really helped."},{"startTime":228.76,"endTime":230.75,"body":"How's the diagnosis confirmed?"},{"startTime":230.75,"endTime":232.41,"body":"[Dr. Handy] Because the viremia is acute,"},{"startTime":232.41,"endTime":235.85,"body":"you have to measure a"},{"startTime":232.41,"endTime":235.85,"body":"viral load directly by PCR."},{"startTime":235.85,"endTime":237.92,"body":"Antibody tests will"},{"startTime":235.85,"endTime":237.92,"body":"probably not be positive"},{"startTime":237.92,"endTime":239.86,"body":"for a few more weeks, at least."},{"startTime":239.86,"endTime":241.69,"body":"[Dr. Wiener] Okay, so"},{"startTime":239.86,"endTime":241.69,"body":"let's get to the question."},{"startTime":241.69,"endTime":245.72,"body":"The question asks, the patient"},{"startTime":241.69,"endTime":245.72,"body":"is at risk for developing"},{"startTime":245.72,"endTime":247.77,"body":"which of the following in the future?"},{"startTime":247.77,"endTime":250.72,"body":"And the options are A. encephalitis;"},{"startTime":250.72,"endTime":252.853,"body":"B. epiglottitis;"},{"startTime":252.853,"endTime":255.628,"body":"C. opportunistic infections;"},{"startTime":255.628,"endTime":258.377,"body":"D. postherpetic neuralgia;"},{"startTime":258.377,"endTime":260.62,"body":"or E. splenic rupture."},{"startTime":260.62,"endTime":263.33,"body":"[Dr. Handy] So, of these"},{"startTime":260.62,"endTime":263.33,"body":"choices, my answer is C."},{"startTime":263.33,"endTime":265.71,"body":"He's at risk of opportunistic infections,"},{"startTime":265.71,"endTime":268.15,"body":"if he doesn't receive appropriate therapy."},{"startTime":268.15,"endTime":269.83,"body":"And like I mentioned before,"},{"startTime":269.83,"endTime":272.153,"body":"the thrush would be one example of that."},{"startTime":272.153,"endTime":273.87,"body":"[Dr. Wiener] Okay, so we're"},{"startTime":272.153,"endTime":273.87,"body":"basing that on the presumption"},{"startTime":273.87,"endTime":276.89,"body":"that he has acute HIV"},{"startTime":273.87,"endTime":276.89,"body":"and will develop HIV."},{"startTime":276.89,"endTime":278.91,"body":"Why are the other options"},{"startTime":276.89,"endTime":278.91,"body":"not correct though?"},{"startTime":278.91,"endTime":281.41,"body":"[Dr. Handy] The encephalitis"},{"startTime":278.91,"endTime":281.41,"body":"in terms of infectious diseases"},{"startTime":281.41,"endTime":282.83,"body":"refers likely to the dreaded"},{"startTime":282.83,"endTime":284.93,"body":"neurologic complication of measles,"},{"startTime":284.93,"endTime":288.24,"body":"which is a subacute"},{"startTime":284.93,"endTime":288.24,"body":"sclerosing panencephalitis."},{"startTime":288.24,"endTime":290.327,"body":"Measles is having a resurgence in the U.S."},{"startTime":290.327,"endTime":292.37,"body":"so that should remain on our differential,"},{"startTime":292.37,"endTime":295.48,"body":"but the patient does not have"},{"startTime":292.37,"endTime":295.48,"body":"the typical rash of measles,"},{"startTime":295.48,"endTime":297.67,"body":"that would be red bumps"},{"startTime":295.48,"endTime":297.67,"body":"that start on the face"},{"startTime":297.67,"endTime":299.83,"body":"and track downwards, plus he reports to"},{"startTime":299.83,"endTime":302.328,"body":"being up-to-date on all"},{"startTime":299.83,"endTime":302.328,"body":"of his vaccinations."},{"startTime":302.328,"endTime":305.88,"body":"I will say that encephalitis"},{"startTime":302.328,"endTime":305.88,"body":"can be a complication of HIV,"},{"startTime":305.88,"endTime":308.47,"body":"but opportunistic infections, like thrush"},{"startTime":308.47,"endTime":310.0,"body":"would be more common."},{"startTime":310.0,"endTime":312.83,"body":"His examination was not"},{"startTime":310.0,"endTime":312.83,"body":"consistent with epiglottitis,"},{"startTime":312.83,"endTime":315.03,"body":"and while he did report some dysphagia,"},{"startTime":315.03,"endTime":318.02,"body":"it wasn't acute and he"},{"startTime":315.03,"endTime":318.02,"body":"didn't report any drooling."},{"startTime":318.02,"endTime":320.19,"body":"[Dr. Wiener] And about"},{"startTime":318.02,"endTime":320.19,"body":"epiglottitis, we should also add"},{"startTime":320.19,"endTime":323.6,"body":"that widespread use of the"},{"startTime":320.19,"endTime":323.6,"body":"H. influenza type b vaccine,"},{"startTime":323.6,"endTime":325.96,"body":"a major cause of acute epiglottitis"},{"startTime":325.96,"endTime":327.73,"body":"has really decreased the frequency"},{"startTime":327.73,"endTime":330.07,"body":"or the prevalence of epiglottitis."},{"startTime":330.07,"endTime":331.81,"body":"[Dr. Handy] Yeah, that"},{"startTime":330.07,"endTime":331.81,"body":"has significantly improved"},{"startTime":331.81,"endTime":334.61,"body":"rates in children where"},{"startTime":331.81,"endTime":334.61,"body":"it occurs more commonly."},{"startTime":334.61,"endTime":337.76,"body":"Just to round out the"},{"startTime":334.61,"endTime":337.76,"body":"remaining answer choices,"},{"startTime":337.76,"endTime":339.96,"body":"postherpetic neuralgia"},{"startTime":337.76,"endTime":339.96,"body":"is a complication of"},{"startTime":339.96,"endTime":341.88,"body":"herpes zoster or shingles."},{"startTime":341.88,"endTime":345.06,"body":"The rash of zoster is a"},{"startTime":341.88,"endTime":345.06,"body":"dermatomal vesicular rash"},{"startTime":345.06,"endTime":348.82,"body":"and is not diffusely maculopapular"},{"startTime":345.06,"endTime":348.82,"body":"like this patient had."},{"startTime":348.82,"endTime":350.67,"body":"And finally, splenic rupture can be"},{"startTime":350.67,"endTime":354.087,"body":"a complication of mononucleosis,"},{"startTime":350.67,"endTime":354.087,"body":"which is a good thought here"},{"startTime":354.087,"endTime":355.56,"body":"but he has no splenomegaly"},{"startTime":355.56,"endTime":357.6,"body":"and it would not explain the thrush."},{"startTime":357.6,"endTime":359.85,"body":"Remember that patients with mononucleosis"},{"startTime":359.85,"endTime":361.5,"body":"that receive ampicillin often"},{"startTime":361.5,"endTime":364.03,"body":"do develop a maculopapular rash."},{"startTime":364.03,"endTime":365.73,"body":"[Dr. Wiener] None of the"},{"startTime":364.03,"endTime":365.73,"body":"answers really referred to any"},{"startTime":365.73,"endTime":368.71,"body":"oncologic causes, which you"},{"startTime":365.73,"endTime":368.71,"body":"had mentioned earlier also."},{"startTime":368.71,"endTime":369.93,"body":"[Dr. Handy] Yeah, we stopped talking about"},{"startTime":369.93,"endTime":372.29,"body":"that early on, as the case presented."},{"startTime":372.29,"endTime":374.61,"body":"Lymphomas are common"},{"startTime":372.29,"endTime":374.61,"body":"cancers in young adults"},{"startTime":374.61,"endTime":376.624,"body":"that can present like this."},{"startTime":376.624,"endTime":379.11,"body":"Solid tumors in a young person like this,"},{"startTime":379.11,"endTime":382.23,"body":"I would be thinking of"},{"startTime":379.11,"endTime":382.23,"body":"testicular cancer or sarcomas"},{"startTime":382.23,"endTime":384.4,"body":"or melanoma, and these can also occur,"},{"startTime":384.4,"endTime":386.64,"body":"so initially, your"},{"startTime":384.4,"endTime":386.64,"body":"thinking would be broad,"},{"startTime":386.64,"endTime":389.14,"body":"but as we learn more about"},{"startTime":386.64,"endTime":389.14,"body":"the case we can narrow"},{"startTime":389.14,"endTime":391.316,"body":"where to begin our initial evaluation."},{"startTime":391.316,"endTime":392.407,"body":"[Dr. Wiener] Okay, great."},{"startTime":392.407,"endTime":395.48,"body":"So the teaching points here"},{"startTime":392.407,"endTime":395.48,"body":"are that acute HIV infection"},{"startTime":395.48,"endTime":397.86,"body":"may present in a fashion"},{"startTime":395.48,"endTime":397.86,"body":"similar to many other"},{"startTime":397.86,"endTime":400.34,"body":"acute viral syndromes or even malignancies"},{"startTime":400.34,"endTime":402.169,"body":"that are common in young people."},{"startTime":402.169,"endTime":404.85,"body":"The diagnosis may be"},{"startTime":402.169,"endTime":404.85,"body":"suggested by the history"},{"startTime":404.85,"endTime":409.5,"body":"and diagnosis requires testing"},{"startTime":404.85,"endTime":409.5,"body":"for HIV RNA with a PCR test."},{"startTime":409.5,"endTime":410.78,"body":"[Dr. Handy] And you can"},{"startTime":409.5,"endTime":410.78,"body":"read more about this"},{"startTime":410.78,"endTime":414.15,"body":"in Harrison's chapters on"},{"startTime":410.78,"endTime":414.15,"body":"cardinal presentation of disease"},{"startTime":414.15,"endTime":416.057,"body":"and on HIV infection."},{"startTime":416.057,"endTime":417.99,"body":"[outro music]"},{"startTime":420.24,"endTime":423.09,"body":"[Mr. Shanahan] This is Jim"},{"startTime":420.24,"endTime":423.09,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":423.09,"endTime":424.72,"body":"Harrison's Podclass is brought to you"},{"startTime":424.72,"endTime":426.69,"body":"by McGraw Hill's Access Medicine,"},{"startTime":426.69,"endTime":428.8,"body":"the online medical resource that delivers"},{"startTime":428.8,"endTime":432.03,"body":"the latest trusted content from"},{"startTime":428.8,"endTime":432.03,"body":"the best minds in medicine,"},{"startTime":432.03,"endTime":434.563,"body":"Go to accessmedicine.com to learn more."}]}