1 / 40

Clinical Problem Solving 12/16/08

Clinical Problem Solving 12/16/08. Moderator: Stuart Cohen MD Discussant: Carlos Estrada MD. Case #1. 21 y/o Caucasian Male presents to clinic with 8 day h/o fever and malaise 2 days PTA developed sore throat Denies myalgias, cough, shortness of breath No nausea, vomiting or diarrhea

LeeJohn
Télécharger la présentation

Clinical Problem Solving 12/16/08

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinical Problem Solving12/16/08 Moderator: Stuart Cohen MD Discussant: Carlos Estrada MD

  2. Case #1 • 21 y/o Caucasian Male presents to clinic with 8 day h/o fever and malaise • 2 days PTA developed sore throat • Denies myalgias, cough, shortness of breath • No nausea, vomiting or diarrhea • Denies nasal congestion, rhinorrhea • Denies headache, stiff neck, visual changes

  3. Case #1 • No rash, joint pain • No dysuria, frequency or urgency • No sick contacts • No recent travel outside of country or hikes in the woods

  4. Case #1 • PMH: None • MEDS: None • Fam Hx: non-contributory • Soc Hx: • Senior at University of Alabama Tuscaloosa • No tobacco or drug use • Social alcohol consumption • Not sexually active

  5. Case #1 • PE: 120/60, 70, 12, 100.2 • HEENT • Erythematous posterior pharynx with cobblestoning, large tonsils with exudate • Bilateral anterior cervical and posterior cervical adenopathy (tender) • CV: RRR with no M/R/G • Lungs: Clear bilaterally, ABD: soft, non-tender, non-distended, No hepatosplenomegaly • EXT: No C/C/E • Neuro: Non-focal

  6. Case #1 • Data • Rapid Strep: Positive • WBC 13.3, HCT 39, Plts 244 • 18% segs, 50% lymphs, 18% Monos, • 8% Atypical lymphs • Monospot: Positive • EBV VCA IgM: Positive • Throat Culture: No growth

  7. Mono/Strep both? • True co-infection with GAS and EBV is rare but reported in the literature • GAS colonization in patients with EBV is more likely (some reports suggest up to 30%)

  8. Centor Criteria • Tonsillar exudates • Tender anterior cervical adenopathy • Fever by history • Absence of cough • 0 or 1 positive  NPV of 80% • 3 or 4 positive  PPV of 50-60%

  9. Diagnostic testing for GAS • Rapid Streptococcal Antigen Test (RAST) • Sensitivity 80-90% • Specificity 90- 95% • Throat Culture • Sensitivity 90% • Specificity 95%

  10. Rationale for antibiotics • To prevent Rheumatic Fever • To prevent peritonsillar abscess • To prevent transmission • To relieve symptoms • For patients with severe pharyngitis, symptoms resolve 2.5 days earlier with antibiotics

  11. Antibiotics in patients with EBV • Macular-papular pruritic rash which is frequently prolonged • Offending Antibiotics • Amoxicillin • Penacillin • Azithromycin • Levofloxacin • Cephalexin • Not reported with Clindamycin • Mechanism of rash unknown • Rash does not presage true drug allergy

  12. Case #2 • 44 y/o white male presents with 3 month h/o left upper extremity weakness • Developed abruptly with no associated pain • limited to distal hand muscles with numbness and paralysis of all finger movements

  13. Case #2 • 1 yr PTA, developed abrupt onset right shoulder pain which lasted for 4 weeks • 1 month after being struck in the neck with water heater • Followed by slow progression of weakness and wasting of shoulder girdle muscles (unable to abduct his arm) • Partial return of function of right arm weakness over past 9 months

  14. Case #2 • Evaluation at University of Michigan 1 yr ago: • MRI brain and c-spine – Normal study • Shoulder films- Normal • EMG: right brachial plexopathy

  15. Review of Systems • Denies recent trauma, vaccines or surgical procedures • No recent fevers, chills, night sweats • Denies chest pain, SOB, cough or dysphagia • Denies abdominal pain, nausea or vomiting • Reports 40# weigh loss over past 9 months • New onset left lower extremity weakness

  16. Case #2 • PMH: • Severe depression with recent psychiatric hospitalization • Right upper extremity weakness (brachial plexopathy) • Meds: Risperdal, lexapro • FamHx: non-contributory • SocHx: • Separated from wife- living at his sister’s house • Past truck driver • Past tobacco use, no alcohol, no drugs

  17. Case #2 • Physical Exam: • VS: AF, 94/60, 60, 12 (weight 115#) • Appearance: Cachectic but NAD • HEENT: OP clear, fundi-no papilledema, no lymphadenoapthy or thyromegaly • CV: RRR with no M/R/G • Lungs: Clear bilaterally • ABD: S/NT/ND/ pos bowel sounds, No hepatosplenomegaly • Ext: NO C/C/E

  18. Case #2 • Neurological exam: • Mental status: normal memory, comprehension and cognition. • Cranial nerves II – XII: visual fields full; extraocular movements intact; facial/jaw strength normal; hearing normal; gag normal; tongue midline without atrophy; normal shrug. • Motor strength testing: • RUE- 3/5 grip, 4/5 wrist flexion and extension, 4+/5 biceps/triceps • LUE- 0/5 grip, 0/5 wrist flexion, 4/5 wrist extension, 4+/5 bic/triceps • RLE- 5/5 strength • LLE- 4/5 strength with foot drop

  19. Case #2 • Neurological exam (cont’d): • Deep tendon reflexes: 2+ everywhere except absent left knee and ankle; toes –downgoing bilaterally. • Sensory examination: Proprioception intact. Vibration diminished in feet and hands. Pinprick diminished in C5/C6 dist on right upper extremity and C8/T1 distribution on left upper extremity. • Coordination: normal finger-to-nose and heel-to-shin testing. • Gait: normal station; normal heel, toe and tandem walking.

  20. Case #2 • WBC 11, HCT 34, Plt 362 • 138 109 22 89 43 29 1.3 • AST 24, ALT 34, AlkPhos 84, Bili 1.0 • Tot protein 7.6, albumin 2.8 • B12, Folate- normal • TFT’s- normal • HIV- negative, HCV- negative, HbsAg- negative • UA: 3+ blood, 2+ protein, >25 RBC’s • Urine Protein/Creatine: 730 mg/24hr

  21. Case #2 • ESR 10, ANA < 1:80, RF (-) • C3,C4,CH50 - normal • SPEP, UPEP, IFE: Negative • P-ANCA (-), C-ANCA 1:320 • Anti-MPO <13, Anti-PR3: 129

  22. Case #2 • CXR- No acute disease • EMG/NCS • Left brachial plexopathy involving lower trunk (C8/T1) • Selective motor denervation in left femoral and posterior tibial innervated muscles (compatible with plexopathy) • Kidney biopsy • Focal necrotizing glomerulonephritis with crescents, pauci-immune • (consistent with ANCA associated vasculitis)

  23. Approach to Weakness

  24. Vasculitic neuropathies • Systemic Vasculitic Neuropathy • Nonsystemic Vasculitic Neuropathy • No associated systemic disease

  25. Systemic Vasculitic Neuroapthy • Pathogenesis • Immune complex deposition • Mixed cryoglobulinemia, Polyarteritis nodosa • Cell-mediated immunity • ANCA associated vasculitides • Patterns of nerve involvement • Ischemic lesions occur randomly along course of peripheral nerve  asymmetric, patchy involvement of both sensory and motor nerves • Longest nerves are affected first • typically lower extremity (sciatic nerve)- often present with foot drop

  26. Systemic Vasculitic Neuroapthy • Clinically present with pain, paresthesias, numbness and weakness • Mononeuritis multiplex • Polyneuropathy • radiculopathy and/or plexopathy • Non-neurologic symptoms of fever, malaise, weight loss and specific organ involvement

  27. Systemic Vasculitides • Primary systemic vasculitides • Microscopic polyangiitis • Polyarteritis Nodosa • Churg-Strauss syndrome • Wegener’s Vasculitis • Secondary systemic vasculitides • Rheumatoid Vasculitis • SLE, Sjogren’s • Hepatitis C and mixed cryoglobulinemia • HIV and CMV • Paraneoplastic vasculitic neuropathy

  28. Wegener’s Vasculitis • Wegener’s • c-ANCA (PR3) 75-90% • p-ANCA (MPO) 5-20% • Pulmonary disease in 70-85% • Glomerulonephritis in 70-80% • Arthralgias/Arthritis in 60-70% • Peripheral nerve involvement reported in up to 40% of cases and often occurs early in the disease course • Nerve involvement can be the first and sole symptom of a beginning systemic vasculitis c-ANCA p-ANCA

  29. Case #3 • 54 y/o WM • seen in ED 2 weeks prior after falling - Left wrist fx • In ED, found to be anemic (HCT 24, MCV 74) • Presents to you for follow-up • ROS: • Diarrhea x many months, watery, yellow, 2-12 BM/day, frequent abd distention • Denies abdominal pain, BRBPR, melena • Arthritis- mostly large joints • Frequent Headaches (No photophobia, blurry vision) • ? Unsteady gait

  30. Case #3 • Pmhx: arthritis • Meds: Naprosyn, Flexeril • Fhx: Non- contributory • Sochx: no tobacco, occ alcohol, No IVDA

  31. Case #3 • PE: AF,135/69, 94, 20, 100% RA • Pale conjunctiva, OP- clear • CV: RRR no m/r/g • Lungs: clear • ABD: soft, mild distention, BS present, No hepatosplenomegaly or bruits • Ext: No C/C/E • Skin: No rashes • Rectal: heme negative • Neuro: normal except for mild decreased vibratory sense in bilateral lower extremities

  32. Case #3 • Data: • Hct 24, MCV 74, WBC 4.5 (nl diff), plts 154 • Chem 7: Normal • Retic 2.1%, LDH 168, ferritin <1 • Fe 8, TIBC 318, B12 175 • AST 54, ALT 48, Bili 0.9, AP 132, Alb 3.2, • Amylase 55, TSH 2.4, FT4 1.0 • 25-OH Vit D 12

  33. Case #3 • Work-up: • Head CT in ED: Normal • Colonoscopy: 2 tubular adenomas o/w Normal • EGD :gastropathy without acute bleed (CLO -) • Scalloped mucosa in duodenum • Biopsy: mucosal inflammation, crypt hypoplasia, villous atrophy • Anti-endomysial Ab: (+) 1: 160 • DEXA Osteoporosis T score: – 3.3 spine

  34. Celiac disease • Epidemiology • Occurs primarily in whites of northern European ancestry • Based on classic symptoms of malabsorption • Prevalence 1:4000- 1:8000 • subclinical or oligosymptomatic celiac diseae • Prevalence 1:250- 1:500

  35. Celiac disease • Pathogenesis • Immune disorder that is triggered by an a environmental agent (gliadin component of gluten) in genetically predisposed individuals • IgA antibodies to gliadin • Ig A antibodies to endomysium • (target antigen: tissue transglutaminase)

  36. Celiac disease • Clinical Manifestations • Diarrhea with steatorrhea • Consequences of malabsorption • Weight loss • Anemia (iron deficiency and b12) • Neurologic disorders from b12 deficiency • Osteopenia from vit D and calcium deficiency

  37. Celiac disease • Associated Conditions • Liver disease • Diabetes Mellitus • Thyroid disease • Myocarditis and cardiomyopathy • GI malignancies & non-Hodgkin's lymphoma • Dermatitis herpetiformis

  38. Celiac disease • Treatment • Gluten free diet • Calcium and Vitamin D replacement • IV Iron • Bisphosphonate

  39. The End

  40. Brachial Plexus

More Related