1 / 24

Severe Leg Pain Diagnosis and Treatment in ER Case Study

A 38-year-old male with a history of HTN and cocaine abuse presents with severe leg pain. Find out the underlying cause, differential diagnoses, treatment, and hospital course in this comprehensive ER case study.

meg
Download Presentation

Severe Leg Pain Diagnosis and Treatment in ER Case Study

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. Red Medicine MR Nirav Pavasia

  2. Case • C/C: My legs are in severe pain • HPI: Pt is a 38 yo BM w/ PMH of HTN, cocaine abuser, presented to the ER w/ swelling and severe pain in both legs. Pt describes pain as sharp and burning, rates 10/10, tender to touch, non-radiating, associated w/ tightness, aggravated by movement and no relieving factors. Reports that the pain has been going on since 1 week but suddenly got worse last night and woke him up from sleep. Pt has not been able to ambulate 2/2 excruciating pain. Pt denies any similar episodes in the past. Pt has noticed subjective fevers and sweats for the past 2-3 days. • Denies any trauma to the LE, recent travel, chest pain, SOB, n/v, dizziness, lightheadedness, abdominal pain, change in bowel or bladder habbits, wt loss or wt gain.

  3. ROS – Otherwise –ve unless stated per HPI • PMH – HTN • PSH – None • FH – HTN, DMII, CAD • SH – smokes 1.5 ppd, >20 yrs; drinks 12pk beer/day, >20 yrs; Snorts cocaine regularly – last use day before admission

  4. VS • Temp: 38.3 • Pulse: 104 • BP: 169/95 • RR: 18 • O2 sat: 97% RA • Allergies – NKDA • Meds – HCTZ

  5. PE • Gen – WN, WD, in mild distress due to severe LE pain • LE – skin hot to touch, shiny, tightness and TTP in bilat LE, strength 3-4/5 due to pain, 4x5” palpable erythematic plaque like lesion in R calf, 2+ peripheral pulses bilat ext, no crepitus noted • HEENT – NC/AT, EOMI, PERRLA, dry oral mucosa, no LADP, no JVD • Chest – CTABL, no R/R/W • CV – tachycardic, RRR, S1S2 nml, no M/R/G • Abd – soft, NT, ND, NABS, no organomegaly • Neurological – AAOx3, CN II-XII intact

  6. Labs • WBC – 24.8 • Hgb – 15 • Platelets – 198 • PT – 14.6 • INR – 1.2 • PTT – 24.8 • Na – 130 • K – 4.4 • Cl – 88 • CO2 – 30 • BUN – 19 • Cr – 1.0 • Gluc – 106 • Ca – 9.6 • CRP – 18 • ESR – 19 • Urine • Cocaine Pos

  7. Any thoughts?

  8. DDx • Cellulitis • DVT • Superficial Thrombophelbitis • Erysipelas • Gas gangrene • Necrotizing Fasciitis

  9. A/P • Cellulitis – bilateral? • Pt started on IV clindamycin, IV vancomycin • blood cx • Get US bilat LE to r/o DVT • X-ray LE, CT LE w/ contrast to r/o gas gangrene and/or necrotizing fasciitis • IVF

  10. Hospital course • Pt continued to spike temperature for next 2 days, highest noted at 38.8 • US LE: -ve for DVT • X-ray, CT LE: wnl, no evidence of soft tissue edema, abscess, or gas noted. Normal limit LE w/o any pathology. No lymphedematous changes or any inflammatory changes were identified in either of the LE. • The erythamatous plaque like lesion in the R calf now beginning to spread in centrifuge fashion towards proximally and appeared in LLE as well around the ankle and toes.

  11. Any thoughts?

  12. Ddx • Henoch Schonlein Purpura (HSP) • Hypersensitivity vasculitis • Wegener Granulomatosis • Churg-Strauss Syndrome (Allergic Granulomatosis) • Polyarteritis nodosa • Buerger Disease (Thromboangiitis Obliterans) • Infective endocarditis • Thrombotic Thrombocytopenic Purpura • Cocaine induced pseudovasculitis • Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

  13. Further work-up • ANA screen – negative w/ <1:40 • CXR, ACE levels to r/o sarcoidosis – CXR unremarkable, ACE levels 59, CT chest – neg for hilar LADP or ILD • HIV Ab – negative • Hepatitis panel – non-reactive • C3 – 151 • C4 – 37 • RPR – non-reactive • TTE – negative for valvular lesions; normal EF; normal heart function • CPK – high at 351 then trended down to 126

  14. Hospital Course • Pt was evaluated by dermatology service and Bx were taken • Pathology report verbal read - neutrophilic infiltration around the small and medium size vessles showing leukocytoclastic vasculitis • ANCA work up – negative • Blood cx – negative • Pt fever controlled w/ tylenol, continued to have severe 10/10 pain in LE, legs were less tight and shiny

  15. Hospital course • Pt was started on solu-medrol 70mg IV per dermatology recs • Over the course of 2-3 days pt’s pain much improved, rated 3-4/10 and erythamatous lesions began to fade away • Vancomycin and Clindamycin stopped as WBC count normalized and pt afebrile for >3 days as well as clinical suspicion less likely for infectious etiology • PT/OT consult placed – pt began to ambulate slowly

  16. Hospital course • Rheumatology consult placed and…

  17. Rheumatology recs - • Cryoglobulin • Human leukocyte elastase • Lactoferrin • Cathespin • Lupus anticoagulant • Beta-2 microglobulin • 3-2 glycoprotein

  18. Hospital course • Pt continued to improve • Pain subsided to 1-2/10 and pt switched to PO steroids • Pt was discharged home and was to follow up as outpt in 2 weeks with rheumatology clinic

  19. Ddx • Cuatneous PAN (CPN) • Hypersensitivity vasculitis • Cocaine induced pseudovasculitis

  20. Thank you

More Related