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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

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clinical problem solving 12 16 08

Clinical Problem Solving12/16/08

Moderator: Stuart Cohen MD

Discussant: Carlos Estrada MD

case 1
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
case 13
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
case 14
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
case 15
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
case 16
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
mono strep both
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%)
centor criteria
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%
diagnostic testing for gas
Diagnostic testing for GAS
  • Rapid Streptococcal Antigen Test (RAST)
    • Sensitivity 80-90%
    • Specificity 90- 95%
  • Throat Culture
    • Sensitivity 90%
    • Specificity 95%
rationale for antibiotics
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
antibiotics in patients with ebv
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
case 2
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
case 213
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
case 214
Case #2
  • Evaluation at University of Michigan 1 yr ago:
    • MRI brain and c-spine – Normal study
    • Shoulder films- Normal
    • EMG: right brachial plexopathy
review of systems
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
case 216
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
case 217
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
case 218
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
case 219
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.
case 220
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
case 221
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
case 222
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)
vasculitic neuropathies
Vasculitic neuropathies
  • Systemic Vasculitic Neuropathy
  • Nonsystemic Vasculitic Neuropathy
    • No associated systemic disease
systemic vasculitic neuroapthy
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
systemic vasculitic neuroapthy26
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
systemic vasculitides
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
wegener s vasculitis
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

case 3
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
case 330
Case #3
  • Pmhx: arthritis
  • Meds: Naprosyn, Flexeril
  • Fhx: Non- contributory
  • Sochx: no tobacco, occ alcohol, No IVDA
case 331
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
case 332
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
case 333
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
celiac disease
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
celiac disease35
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)
celiac disease36
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
celiac disease37
Celiac disease
  • Associated Conditions
    • Liver disease
    • Diabetes Mellitus
    • Thyroid disease
    • Myocarditis and cardiomyopathy
    • GI malignancies & non-Hodgkin\'s lymphoma
    • Dermatitis herpetiformis
celiac disease38
Celiac disease
  • Treatment
    • Gluten free diet
    • Calcium and Vitamin D replacement
    • IV Iron
    • Bisphosphonate
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