Learn more clinical pearls from the Point of Care Medicine Substack!

rokeefemd.substack.com/

The duration of therapy ranges from 14 days for uncomplicated cases to 4-6 weeks or longer for complicated infections like endocarditis or osteomyelitis.

Source: CPS - February 2, 2026 Mainstream Mondays VMR with Youssef & Seeme - fever

Patients on hemodialysis have both structural (the catheter) and functional (uremia-induced) immunocompromise, placing them at very high risk for bloodstream infections.

Staph aureus bacteremia is never a contaminant and mandates a thorough workup for metastatic complications, most importantly infective endocarditis.

Daily Pearl(s):

Catheter-Related Blood Stream Infections (CRBSI)

The absence of erythema, tenderness, or purulence at the catheter insertion site does not rule out a CRBSI; systemic symptoms like fever and chills may be the only manifestation.

Learn more clinical pearls from the Point of Care Medicine Substack!

rokeefemd.substack.com/

A key feature is the discrepancy of a positive PJI biomarker (α-defensin) with negative routine bacterial cultures.

M. bovis is intrinsically resistant to pyrazinamide.

Source: NEJM - Case 7 2026 A 91-Year-Old Man With Left Knee Pain

The clinical presentation is typically chronic and indolent, with insidious onset of pain, swelling, and functional decline, often lacking systemic symptoms like fever.

It can mimic more common causes of late prosthetic failure, such as aseptic loosening or particle disease.

The infection results from hematogenous dissemination of the live, attenuated M. bovis strain, which can seed prosthetic material months to years after the initial therapy.

Daily Pearl(s):

Periprosthetic Joint Infection (PJI) with Mycobacterium bovis BCG

This is a rare, delayed complication of intravesical BCG immunotherapy for non-muscle-invasive bladder cancer.

Learn more clinical pearls from the Point of Care Medicine Substack!

rokeefemd.substack.com/

Source: NEJM - Case 6 2026 A 91-Year-Old Man With Shortness Of Breath, Weight Loss, And Eosinophilia

High IgE - Th2/immune-driven process

High B12 - clonal myeloid expansion (released from eosinophil granules and with myeloid cell turnover)

High Tryptase - mast cell marker; there is often also a systemic mastocytosis when there are oncogenic drivers of myeloid cells present

Daily Pearl(s):

B12 and Tryptase in Eosinophilia

Elevated IgE + normal B12 + normal tryptase = think EGPA or lymphocytic HES

This triad separates immune-mediated from myeloproliferative HES before FISH/molecular testing.

Learn more clinical pearls from the Point of Care Medicine Substack!

rokeefemd.substack.com/

Source: NEJM - Case 6 2026 A 91-Year-Old Man With Shortness Of Breath, Weight Loss, And Eosinophilia

Glucocorticoids are the primary treatment in induction therapy.

Biologic therapies that inhibit the interleukin-5 (IL-5) pathway, such as mepolizumab or benralizumab, are highly effective for managing relapsing disease and as steroid-sparing agents.

A cytoplasmic pattern (c-ANCA) with antibodies to proteinase 3 (PR3) is rare (~5%).

Biopsy of an affected organ demonstrates the classic triad of eosinophilic infiltration, necrotizing vasculitis, and extravascular granulomas.

Labs may show eosinophilia (typically >1500), elevated IgE, and positive Antineutrophil Cytoplasmic Antibodies (ANCA) in 30-40% of cases.

The most common ANCA pattern is perinuclear (p-ANCA) with antibodies against myeloperoxidase (MPO).

A final vasculitic phase with constitutional symptoms, neuropathy (mononeuritis multiplex), skin purpura, and cardiac or renal disease.

Cardiac involvement is a leading cause of mortality.

A prodromal phase with adult-onset asthma and allergic rhinitis.

An eosinophilic phase with high peripheral eosinophil counts and organ infiltration (most commonly lungs and GI tract).

It should be suspected in any patient with adult-onset asthma/sinusitis who develops peripheral eosinophilia and systemic symptoms.

The disease often evolves through phases:

Daily Pearl(s):

Eosinophilic Granulomatosis with Polyangiitis (EGPA)

EGPA is a systemic small-vessel necrotizing vasculitis characterized by asthma, sinusitis, and profound eosinophilia.

Learn more clinical pearls from the Point of Care Medicine Substack!

rokeefemd.substack.com/

Resection via partial nephrectomy is curative, resulting in complete resolution of the hypertension and other abnormalities.

Source: NEJM - Case 5 2026 An 18-Year-Old Woman With Headache And Hypertension

The profound hyperreninemia and downstream effects of angiotensin II can mimic idiopathic intracranial hypertension (IIH), presenting with severe headaches and papilledema.

This typically drives a secondary hyperaldosteronism, although plasma aldosterone levels may be normal or only mildly elevated, as seen in this case.

Plasma metanephrines are normal, which helps differentiate it from a pheochromocytoma.

The overproduction of renin leads to profound activation of the renin-angiotensin-aldosterone system (RAAS), causing severe vasoconstriction (via angiotensin II) and secondary hyperaldosteronism, which results in Na retention and K wasting.

It is a classic cause of secondary hypertension, most often affecting adolescents and young adults.

The hallmark is an extremely high plasma renin activity.

Daily Pearl(s):

Reninoma (Juxtaglomerular Cell Tumor)

A reninoma is a rare, typically benign tumor of the juxtaglomerular cells of the kidney that autonomously secretes excessive amounts of renin.