Source / episode info
- **Episode:**314
- **Title:**Divine Intervention Episode 314 – USMLE Step 2CK Rapid Review Series 57 (+ 2CK/3 May Course Reminder).
- **Published:**2021-05-19
- Source:Episode page
One-liner
This episode provides a rapid review of high-yield topics including the Jarisch-Herxheimer reaction following spirochetal or gram-negative infections, the pathophysiology and management of adrenal insufficiency (AI), steroid pharmacology and toxicities (e.g., myopathy, psychosis), and specific renal/endocrine lab patterns.
High-yield summary
- Jarisch-Herxheimer Reaction: Characterized by fever, chills, and hypotension hours after starting antibiotics for spirochetal or gram-negative infections; caused by the release of endotoxins (LPS) from dying bacteria. Treatment is supportive (NSAIDs, fluids), not steroids.
- Adrenal Insufficiency (AI): Primary AI (e.g., Addison's disease) causes hyperkalemia, metabolic acidosis, and Type 4 RTA due to aldosterone deficiency; secondary AI (steroid withdrawal) requires stress dosing of glucocorticoids.
- Steroid Metabolism: Prednisone is an oral prodrug converted to prednisolone in the liver by 11-hydroxy-stereoday-hydrogenase (11-HSD).
- GI Protection: Chronic steroid use mandates prophylactic PPIs and bisphosphonates due to increased risk of peptic ulcer disease and osteoporosis, respectively.
- Myopathy: Steroid-induced myopathy or hypothyroid myopathy classically present with normal creatine phosphokinase (CK) levels.
- CNS Toxicity: Long-term steroid use can cause "steroid dementia syndrome" via downregulation of glucocorticoid receptors in the hippocampus and prefrontal cortex.
Learning objectives
- Describe the pathophysiology and management of Jarisch-Herxheimer reaction following spirochetal or gram-negative infections.
- Recognize the clinical signs and laboratory abnormalities associated with primary vs secondary adrenal insufficiency.
- Understand the metabolic pathway of oral corticosteroids, including prodrug conversion in the liver.
- Identify key long-term complications of chronic steroid use affecting GI tract, bone, muscle, and CNS.
- Differentiate between various causes of myopathy based on CK levels (e.g., steroid vs. inflammatory).