Sara and Marisu Rueda Altez (University of Alabama Birmingham) chat with the Pediatric ID Fellows Cup (PIDFC) 2026 champions “Sweet Home Histoplasma” (team from UAB) and “RBC BugBusters” (team from Rainbox Children’s Hospital) to tackle the top 5 most missed questions!

For Pediatric ID Fellows Cup (PIDFC) info, please click on the links below!

Sign-up to play in the Fall 2026 game HERE!!

Website: pidfc.notion.site

Follow on Instagram: @pid_fellows_cup

Guests from “Sweet Home Histoplasma”

Rafaella Navarro

Yarlini Vipulanandan

Lindsey Hastings

Guests from “RBC Bug Busters”

Curtis Sudbury

Amber Estes

Lizzie Cahill

Abby Badar

Nada Deraz

Kita Desai

Episodes | Consult Notes | Subscribe | Twitter | Merch | [email protected]

Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi, everyone.

Welcome to Febrile, a cultured podcast about all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics,

and antimicrobial management.

I'm Sara Dong, your host and a Med-Peds ID doc.

I am still working hard to get you caught up on some of the recordings that

we've done over the last few months.

Today, we are joined by several guests, including the champions of

the Pediatric ID Fellows Cup Spring Game, team Sweet Home Histoplasma, and

the runner-up team, RBC Bug Busters.

I'll have everyone quickly say hello and introduce themselves.

We will start off with our Sweet Home Histoplasma team, which is from

the University of Alabama Birmingham

I'm Lindsay Hastings.

I'm a, well, former Med-Peds ID fellow.

Just graduated actually at the end of June, and I'm gonna be starting a

job in Louisville, Kentucky at Norton as a adult ID attending, and then

also doing some teaching and kind of med ed things with our pediatric ID

division at University of Louisville.

Hey, I'm Yarlini.

I am a second-year Peds ID fellow at UAB.

I'm part of the Alabama team

Hi, I am Rafaella Navarro.

I am a third year now.

I was a second year when I was in the, in the team, and I am a Peds resident at UAB

So a couple of our fabulous team members couldn't be here today.

We have Lia Steletou, who is one of our Peds ID fellows, and then we

had two brave adult ID/med-peds ID fellows who also joined our team.

So it's Kaitlyn Hooper and Michaela Myers.

So I wish they could join us today, but they weren't able to be here.

We also have some members of the runner-up team, RBC Bug Busters, which

are joining from Rainbow Children's.

I'm Frederick Curtis Sudbury.

I go by Curtis.

I am now a fourth-year, uh, combined peds ID and peds, um, critical care fellow.

So I still have another two years of this.

I think our whole team's here.

Hi, I'm Keeta Desai.

I'm a Peds ID attending here at Rainbow Babies.

I'm also our

fellowship program director.

Hi my name is Nada Deraz.

I'm a current pediatric resident, former Pediatric ID fellow at Rainbow.

Hi, I'm lizzie Cahill.

I'm a now second-year peds ID fellow and peds hospital medicine combined fellow

Hi, I'm Amber Estes.

I am a now fourth-year Med Peds resident at UH Rainbow and going to be applying ID

Hi everyone.

I'm Abby Badar.

I am a pediatric infectious disease physician assistant

and lastly, we'll give our friend of the show and lead for Pediatric

ID Fellows Cup a chance to say hello

Hi guys.

I'm Marisu Rueda Altez.

I am a Peds ID attending at Children's of Alabama in the

University of Alabama at Birmingham.

I'm one of the leads for the Peds ID Fellows Cup, and I'm super

excited to be here with you guys

Okay.

Well, as everyone's favorite cultured podcast, on Febrile we

always ask our guests to talk about a little piece of culture, just

something that brings you happiness.

Feel like I can kick it off, uh, being a, a bit of a Febrile oldie,

even though I've never actually done the work to, like, be on Febrile.

This is just a little bit of, of nepotism, of being friends with Sara.

But, so my… I mean, uh, the World Cup.

I, uh, someone has to mention the World Cup,

it off and mention the World Cup.

I'm from Peru, so, like, soccer, or futbol, appropriately named,

it's a religion back home.

So I've been following really strongly.

I'm not sure if it's truly a piece of culture, but I was rooting so

hard for Cape Verde this round, even though my husband is, uh, Argentinian

in heart, even though he was born in Peru, and he wants Argentina to pass,

but I really wanted Cape Verde to knock them out in the, uh, round of

32, I was really sad that they didn't.

Nada and I are here in my office, and I, I'm gonna jump on the bandwagon

of World Cup 'cause that was also gonna be my talking point because

my family is a huge soccer family.

I have three children all playing travel soccer.

I also coach my youngest daughter's soccer team, so it's all soccer all the time.

If a World Cup game is on, there's nothing else allowed on the TV.

Unfortunately, since the US is now out, think we've transitioned

to wanting Argentina to win.

So, uh, that's who we're rooting for now.

And for me, I'm from Egypt, so I was like supporting team Egypt.

Um, now I'm not sure exactly, but I think my family, my husband's

like really supporting team France.

Um, I have a lot of different hobbies, and I think right now, lately I feel like one

of my favorites has been, um… I'm really into dance, and the last, like, year and

a half I've been getting back into salsa and bachata merengue, like all types of

Latin dance, um, and have, like, formed a new little, uh, group of friends within

the dance community here in Cleveland.

So it's been a lot of fun to have that break outside of the hospital

I can go.

Um, I can't not be on the World Cup bandwagon.

I lived for a couple of years in Mexico, so was, very for Mexico.

Um, it's a bummer that they're out.

I will vote for Spain right now, I think of those that are left.

Um, but otherwise right now, I just started reading the Dungeon

Crawler Carl series, in case any of you are ever lit RPG people.

They are really funny, bizarre books about, um, basically somebody who

gets thrown into a Dungeons and Dragons-esque world after the world

collapses from an alien organization.

So, in case you need a book recommendation, it

is actually a lot of fun

So have been watching a ton of the World Cup 'cause I'm on maternity leave, but

also have discovered that Apple TV has some of the best dark comedy series.

So shout out to Widow's Bay.

If you haven't watched it, you should.

Right now, um, my husband and I are watching Bad Monkey, which looks like

it has a stupid premise, but it's kinda like if you had CSI Miami, but funny.

It's really good.

Um, and then, like, Margot's got money troubles, but definitely Apple TV has,

like, some of the best comedy that is currently, I think, on streaming right now

Going off of TV, I'm a huge fan of workplace sitcoms.

By far.

I of course love The Office, Superstore, St. Denis Medical, Parks

and Rec, pretty much all of them.

So much so that like some people wake up early in the morning to exercise

before going to work, I wake up early to watch an episode of The Office before

I go into consult service every day

Don't get Marisu started on Friends

I, I was gonna say, I, I think her love for The Office was like 90% of my reasons

for ranking Yarlini so high when we

Now everyone knows, yeah

Goodness, I guess I can go, um, slight- I guess slightly more cultured.

I've been s- reading at night.

I finally got a Kindle this year, and I've been reading, um, Stephen Fry's

Mythos series, 'cause I would always just, like, fall asleep reading the

classics that, like, they force you to read in high school and college and stuff.

It's a really good retelling.

I, like, blew through that, and now I'm on Heroes, and it was really, really good.

Slightly less cultured, we've been super stressed moving, and I don't

know if you all have seen on Hulu, there's this, like, Million Dollar

Nannies series that's, like, all drama.

They're, like, in Ibiza with these families who've got, like,

four-year-olds ordering caviar.

It's very entertaining if you just need to shut your brain off.

Um, all righty, so I am a big coffee drinker.

I really enjoy my morning coffee.

And my favorite Irish-themed coffee shop/bakery, uh, is right by my house.

Um, it's my favorite place to go to get coffee or a treat, either

read a book or do some work.

I will say that back in Peru, my favorite place was going, uh, back

to the beach with my dog, Luna.

And Luna take it, like, really seriously each wave.

The Pacific is a little bit different th-th-the Atlantic.

Um, and now I think that getting together with my friends, sharing

some food, and speaking some Spanish there with them is, like, all my

favorite activities on the weekends

Oh, these are so great.

Everyone will know based on when this comes out how long

it takes me to edit, I guess.

but we are going to chat a little bit about the Pediatric ID Fellows Cup again.

We do have a prior episode, number 127, that we recorded after our first go-round.

This is a collaborative educational tool and competition that we really are

excited about, and it's been designed for trainees, clinicians, really

anyone interested in pediatric ID.

So I'm gonna hand it over to Marisu to tell us a little bit about the

game and some of the stats from this second iteration after we had

our inaugural one back in the fall.

We are super excited about the PedsID Fellows Cup.

We feel like it's been slowly growing with each edition.

We currently just wrapped up the second one, and it's as you guys know, a

collaboration between the Pediatric Infectious Diseases Society Education

Committee and UAB, which is where I work.

It's an initiative based on the successful ID Fellows Cup that was led

by Jeremy Walker, shout out to him, here at UAB as well on the adult side.

And the format for the PedsID Fellows Cup is you have short daily question sets that

are released throughout the competition, just kinda bite-sized learning.

And it's team-based and individual participation as well.

So you get to answer these questions through an app or through the browser.

And the questions come with very detailed teaching explanations that are crafted

by pediatric trainees, all the way from medical students through fellows.

And the emphasis is on board preparation and PedsID learning, but also community

building and, and sort of fostering the next generation of PedsID specialists.

We have some statistics of our, uh, most recent cup.

We had a total of 177 players who started the game, and 127

of them, um, answered all of the questions by the end of the cup.

and 74% of our participants, which is what this cup is kinda aimed at, but

we're welcome, we welcome anyone who wants to participate, were trainees.

and they ranged all the way from residents through fellows.

The majority of our players were first-year fellows.

So we had 37, 29%, and then, um, 29 second-year fellows,

21 third-year fellows.

We had a few residents as well, nine residents total, uh, that participated.

And big shout-out to the 10 players who earned the Chronic Carrier badge.

And bi-even bigger shout-out to those who are present here today,

who are Kita, Rafa, Curtis, and Liz.

And the Chronic Carrier badge is something that you earn if you have

answered every single question of the cup on the day that it was released.

It sounds simple, but it's a big endeavor, and it's actually the spirit

of what we wanted the cup to be.

So learning that is, that happens on a daily basis.

Uh, so yeah, shout-out to you guys, and thank you for being such amazing players.

That's totally because of Curtis.

'Cause our team had a group text, Curtis would remind us all to do our

questions, usually after everybody answered the question, we would comment

on like, "Man, that question was hard," you know, wh- where did we mess up?

What happened?

So it was really cool to kind of have the text chain, um, and that

real time discussion was really fun

That's the perfect transition, because we wanted to ask how you

guys approached the questions.

did you have a captain who was encouraging you to get the questions done?

But anything else, that you guys liked or think that we could improve for

the, um, future edition of the cup?

I'm just gonna give a shout-out.

I think this is really entertaining, but shout-out to the teams with

their really creative names.

It was so fun just to, like, read.

Um, like I loved Sweet Home Histoplasma.

I loved, um, Pitt Tazo.

There were so many other ones that were so cool.

So that was really fun in terms of the community building that

you mentioned as one of the goals.

I love that too.

I think it was like half the fun was just reading all the amusing names.

I like the sort of throwback where you incorporated some of the,

like, previous questions too.

It's good for spaced repetition and adult learning theory and all that good stuff.

So I think that was a nice feature as well this year

I'd say that for, I think pro- probably for the UAB team, which

I was not a part of, uh, it's… I had no hand in them winning.

They're amazing on their own.

But I know that our fellow Lia, who couldn't make it today, Lia Steletou,

was probably the one that was, like, just pushing everyone, "Oh my gosh, Rainbow

has just passed us in the scoreboard.

You guys have to answer your questions." So she was a big, a big part of you

guys' keeping up with questions.

Correct me if I'm wrong.

100% the credit goes to Lia there.

Like, I walk in the fellows office after, like, conference or

something, she'd be like, "Have you all done your questions yet?"

I pretty much answered everything only because I didn't wanna let down Lia.

So it worked

Technically, Kita signed up as our, our captain.

We were joking offline that, um, I was the, the, I don't know,

coxswain, I think is how you say it.

I was like, "Stroke, stroke, stroke. Fill it out. You gotta do it." I would like

set, uh, those send ahead, uh, texts on my phone for when I was on service and

asleep, 'cause I was on night shift.

So it'd be like, "All right, 10:00, they're probably all awake, so a text

then that they all have to fill out their questions." It was a lot of fun though

It's a lot of fun though You made me do it, like, when I was a minute postpartum.

Like, I was still in the hospital and you were bothering me to do it, and I did.

I, I did all the questions, but…

you got the text.

You didn't have to do it one minute post-partum.

just happened to be when the text got there

For the record, Peds ID Fellows Cup, and Febrile endorse people taking their time

off on parental leave, just to be clear

Appre- we appreciate the passion.

Like we did last time, since you guys are our champions, we have

you here to go through some of the commonly missed questions.

So I think Amber's gonna kick off our first question, so I'll hand it over.

All right.

Okay, so our first question was a nine-year-old girl with a history

of allogeneic hematopoietic stem cell transplant for relapsed

acute lymphoblastic leukemia thirty days ago presents with

persistent fevers, progressive cough, and increasing oxy-oxygen

requirements over the last week.

She has been receiving voriconazole prophylaxis, which has been therapeutic.

Laboratory studies show persistent profound neutropenia with an

ANC less than one hundred and elevated inflammatory markers.

Despite broad-spectrum antibacterial coverage and continuation of voriconazole,

blood cultures become positive with microscopy revealing septate hyphae.

A CT scan of the chest demonstrates multiple bilateral pulmonary

nodules with early cavitation.

Lung biopsy shows septate hyphae with acute angle branching and occasional

obovoid conidia invading pulmonary tissue.

Mold isolated in the culture grows rapidly within forty-eight hours, and there's

a picture below, and it shows forming colonies that have dark gray to black

with a dry, velvety to powdery surface.

An image of the fungal colonies, as mentioned, was shown and, um,

not pictured, but if you flip the plate, you can see that they

appear black when observed from the reverse side of the culture plate.

So which organism is the most likely cause of this breakthrough mold infection?

So our answer choices are Aspergillus niger, Fusarium solani, Mucor

circinelloides, Scedosporium apiospermum, and Lomentospora prolificans.

So what do you think the right answer is?

So it was a hard question.

But how do you guys approach it?

Or what, what kind of came through your mind when you

were looking at this question?

So I think when I first saw this question, I was thinking about the

patient and their immunocompromised status, so transplant, and then I

immediately saw the picture and saw the plate with this very striking black to

gray colored colonies that have formed.

From my limited mycology experience, I was thinking Aspergillus

because of transplant, like it can form black colonies.

However, like I was a little stumped with them being on therapeutic

voriconazole prophylaxis.

I was kind of curious like about resistance patterns and

whether that could be at play.

But then ultimately they gave that further detail on like the scope, the microscope

showing that don't fit with Aspergillus.

So that was my initial thought that kind of led me to steer away from Aspergillus.

I think for me, I also thought initially Aspergillus, but I was actually in

the mycology lab at this time, and I thought it was a Scedosporium, but I

was a little bit, I think, confused by the change in taxonomy for it.

So I knew what the genus was, but I didn't have the species right.

So that's why I think I was looking more towards D, um, for it than the L

Yeah, it was a really tough question, and I think what made it even harder

was that the answer choices and the distractors were just chosen so well.

All of them checked a couple boxes from this kind of morphology that they give you

and then kind of your host history, but none of them were quite a hundred percent

there besides that, that Lomentospora.

Um, and really, I think leaned on you having to realize about the kind of

voriconazole susceptibility of it, and then also how it appears in the

microbiology lab, which it's hard to know if you-- we're not spend, you

know, we don't spend quite as much time in the micro labs we used to.

We have electives, which are great.

But I think it's sometimes easy for us to forget what these look like.

And so that clue a lot of times ends up being like not as helpful if you're kind

of having to just go off what you have in your question stem, but you're not really

sure what it should look like in the lab.

Yeah, I would say big shout out to, um, Dr. Campos, one of, uh, the microbiology

lab director from Children's National.

He would drag us to micro lab every single day.

We had micro rounds every day of fellowship.

This is an excellent question written by Nesma Ghanem from Baylor and

mentored by the amazing Jon Albert at UPMC, one of my former co-fellows.

And I think the key, um, detail there was that, uh, when you flip the

plate and you see sort of the black discoloration should hint, hint to you

at this being a dematiaceous fungi.

So that was the main thing that Lomentospora had that

most of the other ones.

And everything you guys mentioned is also very appropriate.

The voriconazole breakthrough component of things.

The condition of the patient making it more likely to have more of this

opportunistic kind of infection.

And then that, that key thing is like which of these fungi

will be a dematiaceous fungi.

Like Aspergillus niger can definitely look black on top, but if you flip

it over, it'll still look kind of pale, creamy look as opposed to the

actual pigment that dematiaceous fungi have that give you that, that black

appearance when you flip the plate.

So Dr. Campos, shout out to you.

You taught me to flip the plate.

Excellent.

Curtis, the next one's yours, right?

So we'll, we'll let you tell us about it.

I wrote two of, two of these five, uh, but I'll do this one.

A five-year-old boy is brought to the emergency department due to

inability to walk that started today.

Parents report that after initially declining routine childhood

vaccines, he has since been following a catch-up immunization

schedule with his pediatrician.

He was diagnosed with chickenpox one week ago, which parents re-report

was isolated cutaneous disease which he recovered without incident.

They saw their pediatrician two weeks ago, and she said that

their child was doing wonderfully.

His vital signs in the emergency department are unremarkable.

He's sitting up in bed and appropriately interactive.

When you ask him to stand up, he's able to do so with assistance but

immediately starts to fall and spaces his feet very far apart to catch himself.

When you ask him to walk, he's able to move around the room in that position but

is unable to walk in a normal fashion.

Strength and reflex testing is normal.

He does not appear to be in pain.

His physical exam is otherwise unremarkable.

Basic labs, including blood counts and chemistries, are normal.

Toxicology testing is pending.

The ED physician has drawn blood cultures and gave a dose

of ceftriaxone and vancomycin.

She ordered a contrasted MRI of the bilateral legs, hips, and

pelvis to look for osteomyelitis.

In addition to the workup already performed, what of

the following should be done?

Admit for administration of IGIV.

Admit to the PICU for high-dose steroids with a planned plasma exchange.

Add on MRI L and S spine with contrast.

Lumbar puncture with opening pressure measurement and send CSF for cell

counts, protein, and glucose.

Or reassurance.

I think we debated this one pretty heavily in our chat.

And also, again, Curtis and I are both combo fellows, so I kinda

also came at this a little bit from like a hospitalist brain too.

I know that the answer is E, reassurance.

I had a really hard time with, uh, picking that one.

Um, and I think I personally went with either C or D.

Partially because I just-- I also-- Fresh out of residency, knowing how

the ED works, I think it's really hard, particularly if you're gonna

get an MRI looking for osteo and you're in that area, to not add

on an L and S spine with contrast.

And I also think in real life, - When you have a patient that is this, um,

undifferentiated, I don't think you're gonna get out of doing an LP personally.

I think I would look for that because aside from, um, varicella,

I mean, the differential's wide open here, so there are other viruses.

Curtis didn't give like a season, but I guess I would also have thought of

like other things that cause neuro issues, such as different arboviruses.

I think that there would just be-- I would want like the full biofile panel.

I might want some other special viral testing thrown in there.

I think it would be hard for me to just give reassurance based

on just the information that we had in the emergency department

I'll piggyback off of what Lizzie said.

We had a heated discussion on, and I think I might have been on service

during the time of the question because this is one of those times

where a test question and what happens in real life sometimes don't match.

And if I were the ID attending on service and got a call from the ED

regarding this case, would I really have been able to say, "Go ahead and

reassure, reassure them that it's, it's acute cerebellar ataxia," without some

of the other workup that Lizzie had mentioned that would happen in real life?

So it was, it was a really good discussion that his, his question

stem definitely should lead you to that, but in real life, what actually

happens are sometimes different

Feel like I have to speak in defense of my question now.

So I wrote this question and one of the questions from the fall, both

as partially as questions to force ID fellows to do things that they're

sometimes not comfortable doing.

The one in the fall was a necrotizing fasciitis diagnosis, and the answer

was you had to, like, call the surgeon and tell them to operate now.

This one was the exact opposite, try to deescalate the situation.

Both of which, in theory, are the right answers, but it's hard to

do as us nice pediatric infectious disease folk, and that was part of

why I wrote this question this way.

That being said, if you meet all the diagnostic criteria for

acute cer-cerebellar ataxia, the guidelines do suggest you do nothing.

That to avoid inadvertent healthcare cost and to avoid finding something that

you then act on that is not the actual cause of the symptoms, that you're

not supposed to do an MRI, you're not supposed to do a lumbar puncture, you're

not supposed to do any of the things.

That's hard.

That that's the guideline, and it feels weird when a kid's not

walking in the emergency department.

But if your reflexes and strength are stone-cold normal, you only

have ataxia, you're afebrile, you're well-appearing, and this super rapid

onset that in the morning, totally fine, three hours later, can't walk normal.

If all of those things fit, and I recognize that I wrote the question

artifically so that everything had to line up perfectly, then you don't do anything.

You just reassure and say, "This is going to last for a while, but it'll get

better on its own." But everything does have to line up perfectly, and I think

all of our feelings that we should be doing more is usually because there's

something that doesn't line up right.

Their kid had a fever or something that makes you really want to

go down that diagnostic pathway.

Would you-- Is there any room in the guidelines, I guess, in this case to obs a

patient either in the emergency department or I could totally see this patient being

admitted for maybe just like an overnight to see if their symptoms progress?

Because I think that's one of the other things is that for ACA, it's

really not supposed to progress.

It's supposed to eventually get better.

Yeah so there is initially a rapidly progressive period and then it's

supposed to slowly get better.

Um, the guidelines say reassure and don't test.

They don't say don't watch the kid.

And I also think it is very likely that most people would admit

this kid for at least 24 hours.

Um, but in theory, you shouldn't be doing any additional testing

Like, I did really like the answer choices 'cause you knew what he

was trying to get you to choose with with each other answer.

Um, I feel like maybe if you said reassurance, observation and

reassurance or something, just, just it was, it was very difficult for me.

That was a very good question.

The only other thing I'll add, I think it's a really good reminder

of how important your neuro exam is.

When I finished like medical school, I was like, "Oh, I'm probably not

gonna have to do this very much in the future." And I actually still have a

reflex hammer for these exact situations.

So I appreciated that about the question.

All right.

Well, we'll move on to the third one I think Lindsay,

you're signed up for this one

All righty.

So a seven-year-old girl is brought to the physician by her

parents for a well-child exam.

She has a history of perinatally transmitted infection with sustained

viral suppression as she has been compliant with her antiretroviral therapy.

At two years of age, she had a dengue infection confirmed by PCR.

She has normal growth and development.

The family immigrated to the US five years ago from the Dominican Republic.

Since then, she's not traveled outside of the country.

The physical exam is normal.

The parents ask about vaccination against dengue prior to moving

back to the Dominican Republic.

Her CD4 T lymphocyte count is five hundred.

What's the next step in management?

A, administer the Dengvaxia vaccine after confirming IgG with a second test.

B, do not administer the as she already has immunity.

C, do not administer the as she is not old enough.

Or D, do not administer the Dengvaxia vaccine because of the

child's underlying immunodeficiency

I will say that when I got this question, the Peds ID Fellow Cup is meant to be

open resource, but you get bonus points if you answer it within two minutes,

and I did the fastest Googling of my life about the Dengvaxia vaccine.

Um, this was

very felt like you have to know ev- all of the indications and contraindications for

Dengvaxia, that is something that we do so uncommonly that I definitely had to, had

to do some very fast Googling on this one.

Um, and otherwise would not frankly have known that seven years old was too young

because I just don't do this enough

We-- Oh, I totally agree, Curtis.

I was like staring at it and like, I don't know what the age cutoff is for this one.

Um, I thought it was a good question in the sense that, like you said, we

don't-- we, we are, you know, spend a lot of time thinking about vaccines, um,

as pediatricians, but not so much about travel vaccines, I feel like in peds ID.

We don't get exposed to that quite as much.

and so that was-- it was a good question to make us think.

I kind of lucked into the right answer in this one, was like, oh, like the cutoff

for a lot of these like travel, like arboviral vaccines and like chik, some of

the chikungunya vaccines is around twelve.

So she seems kind of young.

So yeah, I just kind of really just, just winged it on that one in the

process of elimination, but I thought it was a, a really good question.

Yeah, it was a, it was a good reminder for, um, making sure fellows get access

to our travel clinic and spend some time in travel clinic because I wanna

say this day there was a couple other global health travel-type questions.

And so it's a good reminder of making sure things that we don't always

see commonly, we, we definitely…

And the, the question was phenomenal because there is so much about who can

get the vaccine, what about preceding immunity, what about, um, obviously

age and underlying conditions.

Um, so it was a really nice reminder and refresher.

I got it wrong for sure.

Um, but the teaching points were very good

I will say I also thought this was really hard because, um, I had gone to,

and shout out to the Peds ID Society meeting at St. Jude's every year.

I had gone, this last year, but the year before, and there was a whole

keynote session on dengue and dengue vaccines that are currently available

and those that are in the pipeline.

And that presenter talked a lot about Qdenga that was by far what was more used

in, in Puerto Rico where she was from.

so I had Qdenga in my mind, and so the thought of she's too young

didn't cross my mind at all 'cause I'm like, "Oh yeah, Qdenga, like

this is something that you can, definitely vacci- vaccinate for dengue

in a young child."

So that I did not actually know that Qdenga was not something that was

available in the United States, and that we only had access to Dengvaxia.

I also thought this question highlighted the importance of getting a dengue

vaccine in patients after their first episode of dengue, which I thought

was a really important learning point again, if you don't experience dengue

very much as a clinician, how dangerous the second round of dengue is and how

important doing that, that vaccination is for that patient population

I give a big shout-out to Laura Mendez, who was the writer of this question.

She's ac- was actually our only medical student writer.

Um, and she already signed up to be a writer for the second edition, and

she's committed to the Peds ID, so I'm taking a little bit of the credit of, um,

getting another Peds ID, future Peds ID fellow, uh, she's applying for residency

Yay.

Um, and, uh, and sorry to Laura for giving… I, I feel like w- when I was

taking the Peds boards, this vaccine indication questions were, to me, the

most annoying because I always felt like I can just Google this on the CDC.

Um, but at the same time, I feel like she found a way to a lot of really important

teaching points that you guys have all highlighted, um, in her question.

Like, this is not the, your usual vaccine that you would give, uh, to

prevent them from getting the infection in the first place, but it's actually

to prevent them from getting it a second time, which is something that's

very particular for, for dengue.

Um, and then also a big shout-out to Sanet Torres Torres from Puerto Rico,

who was her mentor and who definitely lives this more in a day-to-day basis

Beautiful.

Okay, we'll go on to question four

So, a five-year-old previously healthy boy presents to the hospital with fever in the

setting of left leg pain for three days.

His mother noticed that he started to limp a few days ago, and then

he was complaining of pain in his left leg over the past three days.

On the day of presentation, he developed fever.

He has no history of trauma to the leg, known allergies, prior

hospitalization, or any recent illness.

He has no known history of MRSA infection or colonization.

He's clinically stable and has tenderness to palpation of his di-distal left thigh.

An x-ray of his left leg is unremarkable, but MRI shows osteomyelitis in the

distal femur with associated myositis.

Using, using your hospital antibiogram below, which empiric

antibiotic would you choose?

And thinking in the people that cannot see the imaging, I will say

that we have, uh, 1112 of Staph aureus in total, and 388 are MRSA.

more or less forty percent, if my math is not wrong, or thirty-eight percent.

and then all the isolates, MRSA and MSSA, are, uh, has a susceptibility

to clindamycin of seventy-three percent, and vancomycin susceptibility

is one hundred in all the isolates.

So, the question is, which empiric antibiotic would you choose?

And the options are cefazolin, vancomycin, clindamycin, and linezolid.

I wanna say I'm getting a lot of friendly fire about this question.

I think it's a great question and I think it highlights a lot of what's

put out in the osteomyelitis guidelines and I think it was beautifully

written by the authors and the mentor.

Um, but I want to know you guys' thoughts on how you approach this

question and how would you deal with this kind of situation if you were-

I feel like this has actually come up not infrequently clinically for us recently.

We have, unfortunately in Cleveland, a rather high percentage of

clindamycin-resistant MRSA, and we do have some clinicians who really want to

reach for clindamycin as their choice, but we are above the 20% resistant to

clindamycin mark, which by guideline would suggest that we should not use it.

So this question I thought appropriately highlighted the risk of using clindamycin

in

presence of high resistance.

Maybe the people who got this one wrong just happen to live in areas

where clindamycin is fortunately still a great option for MRSA.

this I thought was, uh, very well-written.

I also think this question highlights, um, like a very important question that

in ID you're gonna be getting calls about early on is empiric coverage and

guidance on that for different infections.

So I think in this case, like the big question is like, do I add

MRSA or do I not add MRSA coverage?

And, um, for this patient, clinically stable, and no significant known

MRSA risk factors, however, like community rates are high.

So I think that's like the other important learning point.

well, I'll give a shout-out.

This one was written by, um, Alex Linn, who's one of our Med-Peds

ID fellows here in Boston.

Kita, looks like you're signed up for reading this next one

Yes, this question was also written by our favorite Dr. Curtis Sudbury,

and we had a heated discussion about this question as well.

Um, a previously healthy fifteen-year-old boy who's admitted to the PICU with

respiratory failure and seizures.

Three weeks ago, while participating in a volunteer trip to rural Panama during

the rainy season, he developed fevers and a worsening cough after helping

clear muddy fields and dig post holes for a fence around a local school.

He returned home one week ago with persistent cough and intermittent fevers.

On the morning of admission, he developed a generalized tonic-clonic seizure.

He reports taking atovaquone-proguanil as recommended, as well as soaking all his

clothes in 0.5% permethrin and used 30% DEET-based insect repellent every day.

Phenomenal.

He received yellow fever and typhoid vaccines prior to travel.

Parents state that he was not allowed to swim, drink alcohol, ride on a motorcycle,

or interact with animals other than riding domesticated horses during his trip.

In the emergency department, he was febrile to thirty-nine degrees

Celsius, tachycardic, hypotensive, and

hypoxemic

with oxygen saturation of eighty-five percent on room air.

Chest X-ray showed a large right-sided pneumonia with pleural effusion,

so a T-- CT chest was obtained with representative, representative image

below, which we're looking at a, uh, image of a CT scan with, um, what looks

like, uh, infiltrate on right side.

Despite broad-spectrum antibiotics, IV fluids, and supplemental oxygen, he

developed a second prolonged seizure requiring benzodiazepine treatment

and progressive hypoxemic respiratory failure requiring intubation.

Laboratory evaluation showed leukocytosis, thrombocytosis, and

markedly elevated inflammatory markers.

MRI head with contrast was obtained with notable images from

DWI and FLAIR sequences below.

is showing, uh, hypodensity in the left middle, part of the brain.

Based on his presentation and history, which of the following medications

should be administered immediately?

Answer choices are: A, meropenem; B, artesunate; C, s-doxycycline; D,

piperacillin-tazobactam; or E, rifampin

I think this was a really hard question because Curtis literally threw in

every single buzzword for several different infectious disease things.

I mean, he's traveling to, um, a rural third world country.

You've got-- it's the rainy season.

You also have, um, you took a lot of time, uh, to talk about like what type

of insect protection you used ev- he used every day, what vaccines he had.

So I mean, like you had a lot of buzzwords, and then you also had

that statement about what the parents didn't allow him to do.

And so I think it was really hard, um, to get the diagnosis here to figure out that

it was from a Burkholderia, uh, infection.

So, uh, that, that was the hardest for me is I definitely got distracted by

everything else going on in this picture.

Um, and so I think I missed the most important part of this, which was

the fact that the host himself was immunocompetent because I think I

ended up thinking it was tuberculosis.

But I, I think in my head, I looked at the X-ray, I looked at the--

I was thinking CNS, pneumonia.

Okay, it kind of looks like tuberculosis.

But I missed that the host was immunocompetent and kind of

focused more on like where he was digging these holes, like the

country itself and stuff like that

I will say as other people jump in, both for this question, um, Glenn

Rapinski was an excellent mentor.

You're welcome that it was only this long of a question because it

originally was about twice this long.

So thanks Glenn for helping me cut that down.

And for my other question, Walter Dehority from Vanderbilt, um, also did a great

job of cutting down what was literally three times that length of a question.

So, uh, big shout out to both my mentors on these questions

my like Med-Peds like adult ID heart happy 'cause we reason our adult ID group, this

comes up in board review all the time.

They love they love melioidosis, and I feel like it gets emphasized a lot.

I feel like this also is a really good reminder that it's not just in

Vietnam and some of these other like subtropical areas far from, you know,

um, North America and South America.

Like it's here.

It's in, you know, Latin America.

It's in Mississippi.

Like we've had, we've had some cases in the Southern US, so this

is a really good reminder of that

I think the other thing about this question when I-- Like I said, I

think I ended up picking rifampin because of the TB but I think I also

kind of looked at, um, I kind of fell back on just like standard multiple

choice test taking to try to figure it out and so like I looked at what,

what would I be treating with each of them, um, and kind of went from there.

So for me the artesunate malaria I thought that this didn't really fit the

picture of malaria and also the, um, resistance patterns, um, in that area

for what he was taking preventatively.

Um, pip-tazo is not appropriate for the CNS lesions and so it

was really between, um, the mero, the doxy and the rifampin for me.

Um, and the doxy as much as I love doxy for like zoonotic things this

didn't really feel like a zoonotic thing even though it was tropical

and so I often leap there in my mind.

Um, and so it really just came down to the meropenem and the rifampin and

I think in my head I was like, didn't wanna be wrong about TB so that's kind

of how I ended up there because like I said I, I just-- I didn't quite have the

full diagnosis for like the meropenem 'cause it's such a broad spectrum.

I was like ooh I could treat it with-- there's a lot of things I could treat

it with and the rifampin I was like there's less things so that's I think

how I ended up getting the question wrong but narrowing it down to at least the--

at least two choices out of the five

And I just wanna plug that I think that listening to Febrile

can help with questions.

If folks do remember on our melioidosis episode, which featured a couple folks

from the Royal Darwin Hospital, they talked quite a bit about using carbapenem

for critically ill disseminated infection.

So, just to say there-- it's not uncommon that Febrile can help you

answer some of your Peds ID fellowship questions correctly, um, if you

keep up with the, the old catalog.

So I thought I would just plug that episode 'cause it was really great.

So here, let me see.

I think I wrote down - it's episode ninety-four

One more thing that I wanted to say about this question and going back to

what Lizzy was mentioning, um, just sh- shout out to all ID doctors who

answered this question and picked doxy.

I feel like that is always the right answer if you don't know what's going on.

That was the main wrong answer that was picked.

The majority of people picked doxy.

Uh, yeah, and you know, I think in addition to highlighting you guys for

joining the episode today and for your commitment to the PIDS ID Fellows Cup,

we also of course just wanna thank everyone who wrote questions, who

mentored folks and edited questions, and then of course our core organizing

team and the PIDS Education Committee.

For those who don't know, we're taking these questions that have been

previously written and putting them on the PedsID Fellows Cup webpage.

So, you'll be able to go to the website and click through the Q bank, look at

the answers, review questions from prior times, and they will be linked to topics.

So you can search by category if you know that you're giving a talk and you

wanna bring a question on meliodosis, you can, you can type that in.

Uh, it'll have, of course, credit to the authors who wrote the question, and then

it'll also have links to all the resources that are, paired with any of the answers.

So we hope this will be a really good study resource for folks moving forward.

Anything else that folks want to add?

I would just like to say thank you so much to, to you and Marisu for getting

this Fellows Cup going and, and continuing because as a program director to have

phenomenal way of building community within our program, we have our, you our

residents and our PA and like everybody in all the different levels to come together

and just to engage on this is phenomenal.

And then also just the, the amazing education tool that it is

Cool.

And I, I just wanna add also, this is a, a, a living resource, so it's

gonna, it's gonna evolve with time as guidelines change, as we learn

more about infectious diseases.

We're all learning new things every single day.

So I encourage you all as participants to just reach out to us if there's something

about a question that you guys think could be approached a different way or

there's a different answer that you guys would think would be more appropriate

for the question or something that we have to adapt in the questions then.

Like, we're always welcome to feedback.

My hope is for the next edition for my Instagram presence to be less

memes and more actual learning.

I do mostly memes this time to keep-- try and keep people engaged.

But next edition to add more of, like, our expert consults like we did last

time with, um, shout out to Hannah Bajakel at, at putting, um, some teaching

points together about viral-specific T cells in such a short period of time.

Uh, but yeah, I, I welcome all of that, so please just always reach out to us.

The email, um, contact information will be linked to the episode

as well on our-- through our website or through Instagram too.

We're always happy to collaborate with you guys.

We will be recruiting for new players for the fall edition, so you can find

the form to sign up on our website.

You can also follow along with our Instagram to keep up to date.

Don't forget to check out the website, febrilepodcast.com, where

you can find our consult notes, our library of ID infographics,

and a link to our merch store.

Febrile is produced with support from the Infectious Diseases Society of America.

Please reach out if you have any suggestions for future shows or want

to be more involved with Febrile.

Thanks for listening.

Stay safe, and we'll see you next time.