Chiefs’ Inquiry Corner – 2/23/22

February 23, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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As a reminder, xanthomas present are erythematous to yellow papules, plaques or nodules representative of lipid deposition in the skin- there are several different types of xanthomas (tuberous, eruptive, tendinous, plane, verruciform). All of these types are associated with HLD except for verruciform. Cutaneous xanthomas are not life threatening and treatment is not mandatory except for cosmetic reasons. All patients with cutaneous xanthomas should get a lipid panel- if they do not have gross hyperTG (TG > 1000s) or meet otherwise criteria for start a statin therapy then starting on a statin may not improve their existing xanthomas. Different approaches are necessary for the treatment of xanthomas that are not associated with dyslipidemia. Normolipidemic patients with xanthelasma who desire treatment are primarily treated with surgical excision or destructive interventions such as cryotherapy or a 70% trichloracetic acid chemical peel.

References: Xanthoma
  Acute hepatitis C refers to the first 6 months after an infection. Symptoms can begin within 2-26 weeks after infection. A detectable HCV RNA by polymerase chain reaction (PCR) in the setting of undetectable anti-HCV antibodies that subsequently become detectable within 12 weeks is generally considered definitive proof of acute HCV infection. Enzyme-linked immunosorbent assay (ELISA) tests detecting anti-HCV antibodies become positive as early as eight weeks after exposure, with most patients seroconverting between two and six months after exposure. If the HCV antibody is positive at this time point but the HCV RNA is negative, that is suggestive of a prior, cleared HCV infection, and this should be confirmed with repeat HCV RNA after 12 weeks. We typically recheck the HCV RNA at 12 weeks following the estimated date of infection (since most patients who spontaneously clear HCV will do so within this time frame) and initiate treatment if still detectable. Detectable HCV RNA at 12 weeks after exposure predicts chronicity of hepatitis C and indicates a requirement for treatment to prevent ongoing transmission in high-risk groups. Around 25% of patients (but potentially up to 35-40% by some estimates) will spontaneously clear their infections, while 75% will progress to chronic infection, of which 20-30% will develop cirrhosis.

References: Hepatitis C
 The CDC recommends people from a country where TB disease is common be screened for TB. While there is no consensus on a country’s threshold burden of disease for TB screening, the 2021 WHO list of high TB prevalence countries identifies 30 high TB burden countries by incidence per 100,000 per year or high absolute total numbers. Many countries are not in the high burden list, such as the Dominican Republic, which falls in the range of 10-49 TB cases per 100,000 (the same rate as Portugal), but it is on the WHO regional priority list for the Americas for its estimated absolute numbers. Bottom line, while perhaps a lower priority in a visit, it would still be reasonable to screen a patient from the DR!

References: WHO global lists of high burden countries for TB