CPC #2: Plumbism or Promiscuity?

1. CPC #2: Plumbism or Promiscuity? Bridging the Gap. Where Clinical and Basic Sciences Meet Louisa Balazs, MD, PhD Associate Professor of Pathology Amit Malhotra, MD Fellow, Cardiovascular Diseases Karl T. Weber, MD Professor of Medicine

2. Friday morning, September 9, 1956, and Birmingham was abuzz with the prospects of the Tide having another successful season without that Yankee from Beaver Falls, Pennsylvania, at quarterback. The responsibility for this season would fall on the lefty from Muscle Shoals, Alabama. In the University’s outpatient clinic, the ceiling fan made its futile attempt at circulating humid air. Second-year internal medicine resident, Nick Bailey, had just handed a prescription for isoniazid to a 24-year-old woman whose tuberculin skin test had recently converted when he noticed his next patient,

3. Friday morning, September 9, 1956, and Birmingham was abuzz with the prospects of the Tide having another successful season without that Yankee from Beaver Falls, Pennsylvania, at quarterback. The responsibility for this season would fall on the lefty from Muscle Shoals, Alabama. In the University’s outpatient clinic, the ceiling fan made its futile attempt at circulating humid air. Second-year internal medicine resident, Nick Bailey, had just handed a prescription for isoniazid to a 24-year-old woman whose tuberculin skin test had recently converted when he noticed his next patient,

4. Friday morning, September 9, 1956, and Birmingham was abuzz with the prospects of the Tide having another successful season without that Yankee from Beaver Falls, Pennsylvania, at quarterback. The responsibility for this season would fall on the lefty from Muscle Shoals, Alabama. In the University’s outpatient clinic, the ceiling fan made its futile attempt at circulating humid air. Second-year internal medicine resident, Nick Bailey, had just handed a prescription for isoniazid to a 24-year-old woman whose tuberculin skin test had recently converted when he noticed his next patient,

5. Friday morning, September 9, 1956, and Birmingham was abuzz with the prospects of the Tide having another successful season without that Yankee from Beaver Falls, Pennsylvania, at quarterback. The responsibility for this season would fall on the lefty from Muscle Shoals, Alabama. In the University’s outpatient clinic, the ceiling fan made its futile attempt at circulating humid air. Second-year internal medicine resident, Nick Bailey, had just handed a prescription for isoniazid to a 24-year-old woman whose tuberculin skin test had recently converted when he noticed his next patient,

6. Friday morning, September 9, 1956, and Birmingham was abuzz with the prospects of the Tide having another successful season without that Yankee from Beaver Falls, Pennsylvania, at quarterback. The responsibility for this season would fall on the lefty from Muscle Shoals, Alabama. In the University’s outpatient clinic, the ceiling fan made its futile attempt at circulating humid air. Second-year internal medicine resident, Nick Bailey, had just handed a prescription for isoniazid to a 24-year-old woman whose tuberculin skin test had recently converted when he noticed his next patient,

7. Mr. L., carefully negotiating the doorway to the examining room. This disheveled-appearing 44-year-old had a wide-based gait and a right leg that slapped at the floor. Mr. L. complained of weight loss, postprandial bloating relieved by vomiting, as well as shooting pains in his sides.

8. For 15 years he had been gainfully employed as a painter. More recently he had worked in a downtown movie theater, but lost this job when patrons complained he dropped both their tickets and his torch as he staggered “drunk-like” down the aisle ushering them to their seats.

9. For 15 years he had been gainfully employed as a painter. More recently he had worked in a downtown movie theater, but lost this job when patrons complained he dropped both their tickets and his torch as he staggered “drunk-like” down the aisle ushering them to their seats.

10. He fondly recalled several tours of duty with the Navy from 1941 to 1945 and during the great conflict his voyages aboard the USS Missouri to the Pacific included many inviting ports of call where he could comport himself with great alacrity and indeed reckless abandon.

11. He fondly recalled several tours of duty with the Navy from 1941 to 1945 and during the great conflict his voyages aboard the USS Missouri to the Pacific included many inviting ports of call where he could comport himself with great alacrity and indeed reckless abandon.

12. He fondly recalled several tours of duty with the Navy from 1941 to 1945 and during the great conflict his voyages aboard the USS Missouri to the Pacific included many inviting ports of call where he could comport himself with great alacrity and indeed reckless abandon.

13. And, as was the case for many folk livin’ in the rural South, Mr. L admitted to an occasional “taste o’ ’shine,” or moonshine whisky, that he and his pals prepared using a homemade distilling apparatus that included an old car radiator.

14. And, as was the case for many folk livin’ in the rural South, Mr. L admitted to an occasional “taste o’ ’shine,” or moonshine whisky, that he and his pals prepared using a homemade distilling apparatus that included an old car radiator.

15. On examination, blood pressure 140/50, pulse 84/min, 14 bpm. Examination of eyes, ears, nose, neck, throat and lung fields were unremarkable. Apical pulse was displaced leftward and in the 2nd right and left intercostal space a diastolic murmur was audible. Abdomen was benign.

16. The right knee was hypermotile and loose fragments were felt in the joint space; vibratory sensation was absent in both legs. On standing and with his eyes closed, the patient swayed from side to side.

17. Nick considered whether the patient’s illness was a consequence of plumbism or promiscuity. After all, there was commonality between the two. Furthermore, would he prescribe penicillamine or penicillin? The patient was admitted for further evaluation and treatment.

18. Plumbism or Promiscuity Clinical-Pathological Conference Series October 21st, 2004 Divisions of Cardiovascular Diseases and Pathology University of Tennessee Health Science Center, Memphis

19. Historical features of note… • Middle aged male • Recent onset of symptoms • History of possible exposure to lead • employment as a painter for 15 years • moonshine whiskey distilled in a radiator • Lifestyle: possible STD’s

20. Symptoms and Signs • GI: post-prandial bloating and weight loss • CVS: wide pulse pressure, diastolic murmur and cardiomegaly • Neurological: Ataxia worse in darkness, absent vibratory sensation in both lower extremities, right sided foot drop, Positive Romberg’s sign • Musculoskeletal: Deformity of the right knee with hypermotility and loose bodies

21. Disorders that cause multi - system involvement • Vascular/rheumatologic • Infectious • Metabolic/Endocrine • Malignancy • Congenital syndromes

22. Post prandial bloating and weight loss • Obstructive • Neurological • Vascular

23. Cardiovascular • Wide pulse pressure • Diastolic murmur • Cardiomegaly

24. Neurological • Ataxia • Shooting pains • Absent vibratory sensations in legs

25. Musculoskeletal • Neuropathic joint

26. Differential Diagnoses • Tertiary syphilis with aortitis, tabes dorsalis, and gastric involvement • Lead poisoning with abdominal symptoms, and neuropathy

27. Lead poisoning • Anemia • Hypertension • Saturnine gout • Very rarely, dilated cardiomyopathy • Peripheral neuropathy

28. Tertiary syphilis • Luetic aortitis with aortic insufficiency due to aortic root disease • Syphilitic hyperplastic gastritis (linitis plastica) vs. Gummatous pyloric obstruction • Tabes Dorsalis posterior column disease and sensory ataxia and nueropathic pains • Charcot’s joint

29. PLUMBISM OR PROMISCUITY

30. Chronic lead poisoning

31. Treponema pallidum

32. Treponema pallidum-dark field microscopy

33. Syphilis-skin lesions

34. Tabes dorsalis-spinal cord

35. Luetic aortitis

36. Luetic aortitis

37. In 1966, lead poisoning could still be found in painters. It also was common in those who imbibed illegally distilled whisky. Plumbism is accompanied by colicky abdominal pain, peripheral neuropathy with paralysis of often-used muscle groups (e.g., foot drop) and ataxia. Basophilic stippling and increased urinary coproporphyrin levels would be expected.

38. In 1966, lead poisoning could still be found in painters. It also was common in those who imbibed illegally distilled whisky. Plumbism is accompanied by colicky abdominal pain, peripheral neuropathy with paralysis of often-used muscle groups (e.g., foot drop) and ataxia. Basophilic stippling and increased urinary coproporphyrin levels would be expected.

39. Tabes dorsalis likewise is associated with ataxia, but with posterior column and root involvement, a characteristic wide-based gait and slapping movement of an affected leg occurs with subsequent joint destruction (Charcot joint); position sense falters with eyes closed (Romberg’s sign) or when interior lighting is reduced.

40. Tabes dorsalis likewise is associated with ataxia, but with posterior column and root involvement, a characteristic wide-based gait and slapping movement of an affected leg occurs with subsequent joint destruction (Charcot joint); position sense falters with eyes closed (Romberg’s sign) or when interior lighting is reduced.

41. Patients with tertiary syphilis experience lightning-like pains of the abdominal wall and lower extremities; gastric gummas can create pyloric outlet obstruction. Luetic aortitis leads to dilatation of the ascending aorta and valvular incompetence. As a result, the murmur of aortic regurgitation is heard in both the right and left upper thorax. Nick would find intramuscular penicillin his drug of choice.

42. Patients with tertiary syphilis experience lightning-like pains of the abdominal wall and lower extremities; gastric gummas can create pyloric outlet obstruction. Luetic aortitis leads to dilatation of the ascending aorta and valvular incompetence. As a result, the murmur of aortic regurgitation is heard in both the right and left upper thorax. Nick would find intramuscular penicillin his drug of choice.

43. Patients with tertiary syphilis experience lightning-like pains of the abdominal wall and lower extremities; gastric gummas can create pyloric outlet obstruction. Luetic aortitis leads to dilatation of the ascending aorta and valvular incompetence. As a result, the murmur of aortic regurgitation is heard in both the right and left upper thorax. Nick would find intramuscular penicillin his drug of choice.

44. Penicillin will reduce gastric gumma size and regress aortic remodeling.

45. Penicillin will reduce gastric gumma size and regress aortic remodeling.