Episode 253 | May 2026 | Part 1 American Family Physician

Summary

AFP Podcast Episode 253 | May 2026 (Part 1) – Summary

Podcast: American Family Physician Podcast
Host: Faculty & residents, University of Arizona College of Medicine-Phoenix Family Medicine Residency
Release date: May 14, 2026

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Overview

This episode delivers rapid-fire evidence-based updates from the May 2026 issue of American Family Physician (AFP), spotlighting core clinical guidance relevant to everyday family practice. Key discussions include the evaluation and management of severe hypertension, duration of anticoagulation for provoked VTE, pivmecillinam for UTIs, skin and soft tissue infections, atypical antipsychotics for autism spectrum disorder, and recognizing fungal causes of community-acquired pneumonia. Each topic features lively, practical dialogue peppered with pearls, memorable quotes, and actionable algorithms.

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Key Topics & Discussion Points

1. Severe Hypertension: Evaluation & Treatment

(00:30–04:21)

• Redefining Severe Hypertension:
  • Defined as BP ≥180/110 mmHg without target organ damage (TOD).
  • Terms “hypertensive urgency/emergency” are falling out of favor.
  • “These patients have a very low short term risk of adverse events—less than 1% at six months.” (02:02, Justin)
• Management Pearls:
  • No ED by default: Sending patients with isolated BP elevation to the ED doesn’t improve outcomes; often, BP normalizes after rest.
  • Measurement best practices: Automated office BPs are preferred over manual; home monitoring with validated devices also advised.
    • “Supine blood pressures like in inpatient readings tend to run slightly higher than seated.” (02:37, Jake)
  • Labs: Routine labs (BMP, troponin, EKG, UA) not needed unless suspecting secondary causes or monitoring for chronic damage.
    • “Those have not been shown to change management or 30 day outcomes.” (03:00, Justin)
  • Gradual BP reduction: Aim to lower BP over days-weeks, not hours.
  • Avoid reflex PRN antihypertensive meds in hospital: Increases risk for adverse events and doesn’t center on patient evidence.
    • “Those PRNs often come from protocols tied to the 180/110 threshold, not actual patient centered evidence.” (03:28, Justin)
  • Focus on contributors: Address pain, withdrawal, retention, missed meds.
    • “Revolutionary. I know.” (03:50, Justin, tongue in cheek)
  • Discharge most with close follow-up and home BP monitoring.
  • Outpatient: Similar principles—avoid overreaction, titrate thoughtfully, use available algorithms.

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2. Duration of Anticoagulation for Provoked VTE

(04:25–05:38)

• POEM Summary:
  • For provoked VTE with ongoing risk factors (obesity, chronic lung/inflammatory disease), 12 months of apixaban lowered recurrence risk vs. 3 months.
    • “The likelihood of symptomatic recurrent VTE was significantly lower… with an NNT of 11.” (05:22, Justin)
  • Bleeding risk: One major bleed in apixaban group, none in placebo.
    • “It is notable that the researchers were using a prophylactic dose of apixaban and not therapeutic dose for the 12 months.” (05:38, Justin)
  • Practice impact: Longer, low-dose anticoagulation may benefit in certain higher-risk patients.

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3. Pivmecillinam (Pivia) for UTIs

(05:50–08:07)

• Indication/Scope:
  • New β-lactam (penicillin class) for uncomplicated cystitis in adult women due to select organisms (E. coli, P. mirabilis, S. saprophyticus).
• Safety:
  • Similar to other penicillins; contraindicated with serious reactions to β-lactams, acute porphyria, carnitine deficiency, significant renal impairment, or with valproic acid.
• Tolerability:
  • Nausea/diarrhea (<5%), vulvovaginal symptoms (<2%).
  • “It's well tolerated… sounds similar to antibiotics in general.” (07:11, Jake)
• Effectiveness:
  • Effective vs. placebo, comparable to cephalexin; not studied vs. nitrofurantoin, fosfomycin, or TMP-SMX.
• Cost:
  • “Approximately $940 for a three day course… $2,200 for seven days. Nitrofurantoin? About 20 bucks.” (07:39–07:58, Kari & Jake)
• Simplicity:
  • Requires 3x/day dosing.
  • “I don’t love that.” (08:00, Justin)
• Bottom line:
  • Well tolerated, an option for patients concerned about resistance, but not first-line due to cost and comparable alternatives.

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4. Skin and Soft Tissue Infections (SSTIs)

(08:49–12:33)

• Case vignette:
  • 57-year-old man with diabetes, obesity, venous insufficiency—unilateral leg cellulitis, afebrile.
• Diagnosis:
  • Clinical diagnosis; labs/imaging unnecessary unless suspicion for severe or bilateral cases.
    • “Bilateral cellulitis is extremely uncommon… look for other mimics.” (09:48, Kari)
• Mimics: Venous stasis, DVT, lymphedema, dermatitis.
• Treatment:
  • Mild non-purulent: First-gen cephalosporins for 5 days.
    • “Five days is as effective as longer courses for mild infections.” (10:27, Kari)
  • Severe/systemic: Hospitalize, labs (CBC, BMP, blood cultures), imaging for necrotizing infection, IV antibiotics.
• Abscesses/Furuncles:
  • Incision & drainage (no packing); adjunct antibiotics (clindamycin or TMP-SMX) to reduce failure risk.
• Prevention:
  • Control chronic conditions (especially diabetes), treat any superficial fungal co-infections, consider compression stockings for recurrent cases (NNT = 4).

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5. Atypical Antipsychotics in Autism Spectrum Disorder (ASD)

(12:33–14:20)

• Clinical question: Do atypical antipsychotics help manage behavioral symptoms in ASD?
  • FDA-approved: Risperidone, aripiprazole for irritability (kids ≤17).
• Evidence:
  • “In kids… may reduce irritability over about 3 months, but there’s insufficient evidence in adults.” (13:07, Jake)
  • Modest improvements (not always clinically meaningful) on Aberrant Behavior Checklist.
    • “The improvements were modest and not clearly clinically meaningful.” (13:33, Kari)
  • Other symptoms (OCB, speech): Aripiprazole (spectrum), risperidone (speech only).
  • Poor data on aggression, no evidence for sustained benefit >3 months.
  • Quality of trials: small, inconsistent (Strength of recommendation: B).
• Guidelines: Use these meds cautiously, temper expectations.

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6. Diagnosing Fungal Causes of Community Acquired Pneumonia (CAP)

(14:20–20:28)

• CDC & Mycose guidelines reviewed; moderate trust score (4/8):
  • Not based on systematic reviews or graded evidence; minimal patient input.
• Fungal CAP Overview: Focus on coccidioidomycosis, histoplasmosis, blastomycosis—often missed causes of pneumonia.
• Coccidioidomycosis:
  • Test in CAP/erythema nodosum with respiratory symptoms in high-risk regions (South-central AZ, San Joaquin Valley).
  • Also test if unexplained CAP continues after antibiotics in relevant travel history.
  • Testing: Serum EIA antibody (add immunodiffusion/complement fixation for specificity); repeat testing if suspicion remains high.
  • “PCR testing… low sensitivity and can only be performed on tissue samples.” (17:00, Kari)
• Histoplasmosis:
  • Suspect in CAP with bird/bat exposure, specific radiographic/dermatologic findings.
  • Test in CAP not improving post antibiotics in endemic regions (Midwest, Great Lakes, Ohio/Miss. valleys, parts of Americas, etc.).
  • Testing: EIA urine antigen first, then antibody testing—cross-reacts with blastomycosis, but therapies similar.
• Blastomycosis:
  • Suspect with CAP + verrucous skin lesions (gray-violet, irregular border).
    • “The characteristic cutaneous finding is a verrucous lesion...” (19:05, Jake)
  • Test with EIA urine antigen and, if negative/suspicion persists, culture, microscopy, or biopsy.
• Consult ID or pulmonary if diagnosis unclear and severe or persistent symptoms.

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Notable Quotes & Memorable Moments

• On the real risk of severe hypertension:
  “So should I be prescribing a chair?” (02:22, Kari — on the value of rest over panic)
• Cost of new antibiotics:
  “Yeesh.” (07:58, Jake — responding to the price of pivmecillinam)
• Evidence grading transparency:
  “Let’s look at the GTrust scorecard for trustworthiness, relevance, and utility. It’s a four out of eight…” (14:57, Kari)
• Clinical wisdom in infectious disease:
  “Bilateral cellulitis is extremely uncommon and so if you see what appears to be bilateral cellulitis, look for other mimics.” (09:48, Kari)
• On antipsychotics in ASD:
  “The improvements were modest and not clearly clinically meaningful.” (13:33, Kari)

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Timestamps for Key Segments

• Severe Hypertension Discussion: 00:30–04:21
• VTE Anticoagulation Duration (POEM): 04:25–05:38
• Pivmecillinam (STEPS): 05:50–08:07
• Skin & Soft Tissue Infections: 08:49–12:33
• Atypical Antipsychotics in ASD: 12:33–14:20
• Fungal Causes of CAP: 14:20–20:28

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Takeaway Themes

• Many acute primary care concerns benefit from a measured, evidence-based approach over knee-jerk testing or escalation.
• Newer drugs or strategies (e.g., pivmecillinam, longer VTE therapy) may have a niche but must be weighed against cost, convenience, and established alternatives.
• Common conditions like skin infections and severe hypertension often hinge more on foundational clinical skills and contextual judgment than on reflexive protocols.
• For challenging and chronic issues (ASD behaviors, recurrent infections), modest improvements and careful expectation management are key.
• Awareness of regional/epidemiological risks (such as fungal pneumonias) is essential, especially with unexplained treatment failures.

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For further questions or feedback, listeners are encouraged to reach out to the AFP Podcast at [e-mail] or follow on Instagram @fpjournal.

Transcript

[A]

The AFP podcast is brought to you by the American Academy of Family Physicians and by Elation Health. With Elation's AI billing, family medicine practices see denial rates below 5% versus the industry average of 15 to 20% and get paid in about 10 days. It's delegation, not just automation. [e-mail] AFP.

[B]

Welcome to the American Family Physician podcast for part one of the May 2026 issue. I'm Jake.

[A]

I'm Justin.

[B]

I'm Kari and we are residents and faculty, mostly residents of the University of Arizona College of Medicine Phoenix Family Medicine residency programs. Today on the podcast we'll talk about severe hypertension, treatment of provoked vt, El pibmacillinam, skin and soft tissue infections, treatment of behavioral symptoms in autism spectrum disorder and fungal causes of community acquired pneumonia.

[C]

The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health do not use this podcast for medical advice. Instead, see your own family doctor for medical care.

[B]

We're on a mission delivering the best from American Family. First up, we have a main topic, Severe Hypertension evaluation and treatment. And this comes to us from doctors Gower, Refot and Blankenship from Womack Army Medical center in Fort Bragg and Eisenhower Army Medical center in Fort Gordon.

[A]

This matters because there aren't many evidence based guidelines here compared to routine hypertension care and the AHA has moved away from hypertensive urgency and and define severe hypertension as greater than OR equal to 180 systolic or 110 diastolic without target organ damage.

[B]

And importantly, these patients have a very low short term risk of adverse events less than 1% at six months.

[A]

Right. And sending them to the ED for isolated BP elevation hasn't been shown to improve outcomes. In fact, about 1/3 will drop to around 16090 after 30 minutes of rest.

[C]

So should I be prescribing a chair?

[A]

You know it's not the worst idea, but also, automated office blood pressures are more accurate than manual and better reflect ambulatory readings. Home monitoring with validated devices is great too.

[B]

Quick Pearl here. Supine blood pressures like in inpatient readings tend to run slightly higher than seated.

[A]

What about evaluation? Patients may have mild symptoms like headache or dizziness, but in the absence of target organ damage, routine labs aren't necessary.

[C]

Okay, so I don't need to be getting a reflex, bmp, trops, ekg, ua, the works?

[A]

Exactly. Those have not been shown to change management or 30 day outcomes. Just focus testing on secondary causes or monitoring for chronic damage when indicated.

[B]

Let's talk management.

[A]

Our key principle here is gradual BP reduction over days to weeks with close follow up.

[C]

But in the hospital, shouldn't we just throw in some PRN meds?

[A]

Sure, if you're okay with higher risks of AKI, stroke, MI hypotension, longer stays and mortality.

[C]

Okay, you're right. I am less okay with that.

[A]

Exactly. Those PRNs often come from protocols tied to the 180110 threshold, not actual patient centered evidence.

[B]

So what should we do?

[A]

Start by addressing contributors. Things like pain, anxiety, withdrawal, hypervolemia, urinary retention, med issues and non continued or missed home meds.

[C]

Yes, the classic take a good history approach.

[A]

Revolutionary. I know. If BP stays elevated after a few hours and the patient is high risk or has prior severe hypertension, sure, you can consider med adjustments. Otherwise observe discharge with close follow up and monitor blood pressure at home.

[B]

And what about in the outpatient setting?

[A]

You can manage this without sending everyone to the edge. Kind of similar here. Adjust contributing factors, track home readings and titrate meds thoughtfully. There's a nice algorithm in the article for both outpatient and inpatient management.

[C]

So less panic, more patience.

[A]

Perfect. Dr. Staus,

[B]

next up, we have a poem, and this one comes to us from Dr. Mark Abel, a hot topic recently.

[A]

How long do we really need to treat venous thromboembolism?

[C]

Yeah. So the bottom line of this poem is that in patients with a provoked VT EL and an ongoing risk factor which the article states, specifically obesity, chronic lung disease or chronic inflammatory disease, 12 months of apixaban reduced recurrent VTE compared with 3 months of treatment.

[B]

How does that differ from current guidelines?

[A]

Great question. It is recommended to complete three months of anticoagulation with a direct oral anticoagulant or DOAC for patients with a provoked VTE defined by VTE occurring with major surgery, trauma, acute medical illness or immobility.

[C]

In this study, the research group studied participants who had a provoked VTE. Everybody took therapeutic doses of apixaban for three months and then were split into two groups. One took apixaban 2.5mg twice daily for 12 months and the other group took a placebo for 12 months.

[A]

The likelihood of symptomatic recurrent VTE was significantly lower than the placebo group with an NNT of 11.

[B]

All right, so less recurrent VTEs. What about harm?

[C]

There was one episode of major bleeding in the apixaban group with none in the Placebo group.

[A]

This is really interesting. It is notable that the researchers were using a prophylactic dose of apixaban and not therapeutic dose for the 12 months of anticoagulation. But I suspect this will further help to inform all our practice.

[B]

Yeah, guys, we have a steps and this one looks at pivmicillinam or pivia. It comes to us from Drs. Diletti Swenson and Dr. Feng Feng from Tufts in Boston.

[C]

Pivmocillinam, name brand Pivia, is a beta lactam antibiotic in the penicillin drug class that is labeled for treatment in adult women with uncomplicated cystitis caused by susceptible isolates of E. Coli, Proteus mirabilis and Staphylococcus saprophyticus.

[B]

So this is a newish antibiotic option for treating UTIs, especially in patients in whom antibiotic resistance is a concern. Let's dive into the steps, the safety, tolerability, effectiveness, price and simplicity for this new med.

[A]

First, safety. It has a safety profile and risk similar to other penicillin antibiotics and it's contraindicated in people with a history of serious reactions to beta lactam antibiotics specific to pivmicillinam. It is linked with acute porphyria and associated with a carnitine deficiency, so avoid it in patients with those concerns. It should not be taken with valproic acid or valproate or patients with significant renal impairment or decreased muscle mass because of the carnitine concerns.

[C]

Next, tolerability. It's well tolerated. Most common adverse effects are nausea and diarrhea, both in less than 5% of patients and vulvovaginal symptoms in less than 2% of patients.

[B]

All right, so it sounds similar to antibiotics in general. What do we know about its effectiveness? Justin?

[A]

Well, it's only been studied in three trials at the approved dose. Comparing it to cefalexin or no antibiotics, it was found to be more effective than no treatment or placebo and similarly effective to cefalexin. Importantly, it hasn't been studied against other first line choices like nitrofurantoin fosfomycin or trimethoprim sulfamethoxazole. And it hasn't been studied against gram negative aerobes other than E. Coli.

[C]

Specifically, it may be an effective option, but it's also an expensive one. When we look at the price, it's approximately $940 for a three day course of nine 185 milligram tablets or $2,200 for a seven day course. In comparison, a five day course of Nitrofurantoin costs about 20 bucks.

[B]

Yeesh.

[A]

It's also not super simple. It's a three time per day dosing. I don't love that.

[B]

Yeah, me neither. Bottom line it for us Kari.

[C]

Pivmycillinam is well tolerated, but it has less convenient dosing than other useful treatments for uncomplicated uti. It may have a role in treatment of acute cystitis in patients in whom antibiotic resistance is a concern, but it should not be considered for routine first line use due to its high cost.

[B]

We'll be back with more AFP Podcast after this.

[A]

The AFP podcast is brought to you by the American Academy of Family physicians and by ChartNote. Tired of pajama time? More physicians are turning to AI to simplify documentation. ChartNote is a HIPAA compliant platform designed for physicians. Its ambient AI scribe listens during patient visits and drafts notes using custom templates that match your style.

[B]

See how it [e-mail] we have another main topic, skin and soft tissue infections. And it comes to us from doctors Chamblisse, Rumbal and Brown from Cone Health Family Medicine Residency Program in Greensboro, North Carolina.

[C]

Let's kick off this discussion with a case. We have a 57 year old male, we'll call him Ed Ema, with a history of diabetes, obesity. Okay, with a history of diabetes, obesity and bilateral venous insufficiency, coming into the office with what appears to be a small area of cellulitis of his right leg. He's not experiencing any fevers or other vital sign abnormalities at this point.

[A]

I see what you did there, Dr. Staus. This sounds like a mild infection given there are no systemic markers of infection, and because cellulitis is a clinical diagnosis, we don't actually have to get labs or further imaging if our index of suspicion is low.

[B]

Other physical exam findings might include red streaking or tender regional lymphadenopathy.

[C]

One of the most important findings in this case is he has unilateral symptoms. Bilateral cellulitis is extremely uncommon and so if you see what appears to be bilateral cellulitis, look for other mimics.

[A]

These can include, but aren't limited to venous stasis, which ED has dvt, lymphedema and atopic dermatitis.

[C]

Okay, so let's say we've made our diagnosis and we treat him as a mild cellulitis for non purulent ssti or skin and soft tissue infection. An uncomplicated cellulitis should be treated with antibiotics that cover methicillin sensitive Staph aureus and Streptococcus species such as first generation cephalosporins.

[B]

And how long should we treat for?

[C]

Five days is as effective as longer courses for mild infections. If we are considering moderate to severe, this should be closer to seven to 14 days.

[B]

All right, let's say our pal Edema presented Febrile, this time tachycardic and had tense bulli in his affected leg.

[C]

Yeah, that sounds a lot worse. I would have a pretty high suspicion for a more severe SSTI and would want to rule out a necrotizing infection because that is a surgical emergency and would require debridement.

[A]

In this case, we would want to transfer to the emergency department and obtain labs. We'd want to get a CBC to look for a white count greater than 10,000, a metabolic panel to evaluate for end organ damage like an aki and blood culture since he is experiencing severe systemic symptoms.

[C]

And what labs don't we need?

[A]

CRP and Procal. They're actually not so helpful because they may be elevated in mimics like VTE. And superficial swabs for culture are usually contaminated with skin flora and thus not helpful.

[B]

And of course, since we're worried about a necrotizing infection, we would want to get a CT or MRI.

[C]

This infection would also require IV antibiotics, and I encourage you to consult Table 4 for appropriate antibiotic therapies.

[A]

What about abscess and carbuncles and furuncles?

[C]

Great question. Abscesses often occur in areas of skin friction or minor trauma. And carbuncles and furuncles are subtypes that are located adjacent to sweat glands or hair follicles. Abscesses require incision and drainage, but not packing. And after an IND treatment includes clindamycin or trimethoprim sulfamethoxazole to reduce risk of treatment failure.

[B]

Okay, so ED does really well outpatient with ceflexin for five days. Do you have any pearls to help him avoid future infections?

[C]

Yes, I do. We need to control his chronic conditions, especially his diabetes. And if he has any superficial fungal infections on the affected extremity, we need to treat those, too. And actually, if he develops another cellulitis on the same leg within two years, I would recommend compression stockings, which can reduce the recurrence of cellulitis with an NNT of 4.

[B]

Next up, we have a Cochrane for clinicians atypical antipsychotics in management of behavioral symptoms in autism Spectrum disorder. It comes to us from Drs. Urban Scheele and Sonoda from St. Louis University School of Medicine in Missouri.

[A]

Limited access to support plus challenging behaviors like irritability, aggression and self injury can be tough to manage. So the question here is, do atypical antipsychotics actually help? FDA wise? We've got risperidone and aripiprazole approved for irritability in kids up to age 17 with ASD.

[B]

Yeah. So the answer is kind of A Cochrane review of 17 randomized control trials. Only one that included adults looked at this. In kids. Both meds may reduce irritability over about three months, but there's insufficient evidence in adults.

[A]

They also looked at obsessive compulsive behaviors in speech. Aripiprazole improved both, while risperidone mainly helped with inappropriate speech.

[C]

But, and this is important, the improvements were modest and not clearly clinically meaningful.

[B]

And for adults, well, basically not enough evidence to say anything useful.

[A]

The primary outcome was the Aberrant Behavior Checklist. Irritability Scale. Scores improved, but again, not dramatically.

[C]

Also not so solid data on aggression. And no studies beyond three months showing lasting benefit.

[B]

Plus these studies were small and inconsistent. So overall, we're dealing with limited quality evidence. A strength of recommendation B.

[A]

Guidelines from both U.S. and European child psychiatry groups say to use these meds cautiously.

[C]

So bottom line, risperidone and aripiprazole might help a bit in kids, but you gotta temper your expectations.

[B]

We're gonna wrap this episode up with a practice guideline diagnosing fungal causes of community acquired pneumonia. And it comes to us from doctors Hamrick and Hamrick from the Baldwin Health Family Medicine Residency in Foley, Alabama. Do you know Foley?

[A]

Yeah, one of my classmates in med school is at that program right now.

[B]

Oh, cool.

[A]

The Centers for Disease Control and Prevention and MYCOSE Study Group Education and Research Consortium release guidelines on when and how to test for fungal etiologies of pneumonia.

[C]

That's a mouthful.

[A]

Yeah. Geez.

[B]

Nicely done.

[A]

Cdc pmsgerc.

[C]

All right, before we jump in, let's look at the GTrust scorecard for trustworthiness, relevance and utility. It's a four out of eight missing points for not being based on systematic reviews, not providing evidence graded by quality, not having the chair and majority free of conflicts of interest. And finally, the development group did not include patients. Ideally, the group should include the most relevant specialties, patients and payers.

[B]

Good frame of reference there. And as editor Dr. Michael Arnold points out, though, even with its low score, it still gives us some helpful background. So let's jump in. This guideline is focused on testing when it comes to three seemingly under recognized fungal infections that can present as community acquired pneumonia.

[A]

First up, coccidioidomycosis. Here in Arizona, this is always on our radar. We're the epicenter baby. But for people outside of Arizona, here are the pearls.

[C]

Initial testing is recommended for patients who present with CAP or erythema nodosum with recent respiratory symptoms who live in regions where cocci is highly prevalent. This is south central Arizona and the San Joaquin Valley of California.

[A]

Testing should also be considered for patients with apparent CAP with continued symptoms after empiric antibiotic treatment if they live in or have traveled to an area where coccidioidomycosis is prevalent. This includes Arizona, California, Nevada, New Mexico, Texas, Utah, Washington, Central America, and South America.

[B]

A serum enzyme immunoassay antibody or EIA test should be obtained initially if available. Immunodiffusion and complement fixation testing should be included because they have greater specificity than EIA antibody alone despite a negative test. If clinical suspicion remains high, symptoms progress or symptom onset is recent. Repeating serology in two to six weeks, obtaining sputum or bronchoalveolar lavage, culture and microscopy, or consulting an infectious disease or pulmonary specialist should be considered.

[C]

Polymerase chain reaction or PCR testing has low sensitivity and can only be performed on tissue samples. Antigen testing should be used in immunocompromised patients with a negative serum antibody test.

[B]

Next up, histoplasmosis.

[A]

Testing for histoplasmosis should be considered in patients with CAP who have a history of exposure to bird or bat droppings or a chest radiograph showing a new nodule or lymphadenopathy consistent with histoplasmosis. There are also some rheumatologic symptoms that should steer you toward testing, including myalgias and arthralgias, as well as dermatologic findings of erythema nodosum or erythema multiforme.

[C]

The guideline also recommends testing for histoplasmosis in patients with CAP whose symptoms do not improve with antibiotics and who live in or have traveled to an area where histoplasmosis is prevalent. These regions include the central and eastern United States, with the highest prevalence in the Ohio and Mississippi river valleys and and the Great Lakes region. Histoplasmosis is also found in eastern, central and South America, the Caribbean, Central Europe, southern Africa, and Southeast Asia.

[B]

The recommended test for histoplasmosis is EIA urine antigen testing followed by immunodiffusion and complement fixation antibody testing. A positive antigen test is reliable and although cross reactivity with blastomycosis you'll hear about more in a second is high, the antifungal therapy for these conditions is

[A]

unlikely to be different and if testing is negative but clinical suspicion is high. For histoplasmosis, immunodiffusion and complement fixation testing should be repeated. Sputum or bronchoalveolar lavage culture and microscopy should be performed or an infectious disease or pulmonary specialist should be consulted. Polymerase gene reaction testing is rarely available but can be performed on serum bronchoalveolar lavage or tissue samples.

[B]

All right, and lastly, blastomycosis Testing for blastomycosis is recommended in patients with community acquired pneumonia presenting with skin lesions consistent with blastomycosis. Do you guys remember what these look like?

[A]

Bully close. I'm just guessing.

[B]

I didn't remember the characteristic cutaneous finding is a verrucous lesion with irregular borders and the color can range from gray to violet. If you want to see a great case example, the AFP photo quiz from way back in the November 15, 2007 issue is available online and a great

[C]

example testing should also be considered in patients with CAP after ineffective antibiotic therapy if they live in or have traveled to a region where blastomycosis is prevalent. These include the Midwestern, south, central, Northeastern and southeastern United States, with the highest prevalence in northern Minnesota and Wisconsin. International areas include Africa and India.

[A]

Like histoplasmosis, EIA urine antigen is the test of choice, again with some risk for cross reactivity with histoplasmosis. If the EIA urine antigen test is negative, the risk for blastomycosis is low. For patients with a high suspicion for blastomycosis or continuing symptoms, sputum or bronchoalveolar lavage culture and microscopy, biopsy of characteristic skin lesions and serum antibody testing should be considered or consultation with an infectious disease or pulmonary specialist. Signs of disease in the bone or gastrointestinal or urinary tracts are strongly suggestive of blastomycosis.

[B]

Send us your thoughts by emailing [e-mail]

[A]

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[C]

Please subscribe and rate us wherever you get your podcasts. Escuchenos en Espanol Arrevista Medica A FAP Our podcast team is Jake Anderson, Puneet

[A]

Barot, Steve Brown, Justin Chettiak, Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisum Okuagu, and Kari Stauss.

[C]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabs, Ryan Evans, and Justin Jenkins.

[A]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs.

[B]

We'll talk to you soon for the next edition of the American Family Physician Podcast.