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CPC COMPETITION Chicago, IL

CPC COMPETITION Chicago, IL. October 12, 2014 Nicole Maguire, DO, FACEP Newark Beth Israel Medical Center Emergency Medical Associates. INFORMATION FROM CASE PRESENTATION. 11 year old female who is brought in by her mother for acting “strange and erratically.”

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CPC COMPETITION Chicago, IL

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  1. CPC COMPETITIONChicago, IL October 12, 2014 Nicole Maguire, DO, FACEP Newark Beth Israel Medical Center Emergency Medical Associates

  2. INFORMATIONFROM CASE PRESENTATION • 11 year old female who is brought in by her mother for acting “strange and erratically.” • Reports “bugs are crawling all over her”. • Sees and feels spiders crawling on her.

  3. INFORMATIONFROM CASE PRESENTATION • Patient and mother also report the following: • Feeling “HOT” • Lower Abdominal Pain • Headache • Waxing and Waning episodes of AMS • Symptoms worse at night • Insomnia • Heightened Energy

  4. INFORMATIONFROM CASE PRESENTATION • Patient reports taking Motrin and “pink pills” • Patient had a sore throat one month ago. • Has a rash on axilla that is red and swollen. • House was recently sprayed for bugs. • No sick contacts. • Not sexually active. • No change in diet.

  5. Medical History • Night Terrors age 2-4 • Menarche 1 year ago • Sore throat one months ago – Strep Negative • Two surgeries for lazy eye.

  6. Physical Exam • VS – BP-121/81 P-100, RR 18, Sao2-100% T-99.5 • General: Alert, no acute distress, not ill or toxic appearing • Skin: Warm, dry, cheeks flushed, red raised rash in right axilla, one larger spot approximately 2.5 cm x 2.5 cm with satellite lesions • Head: Normocephalic, atraumaticNeck: Supple, trachea midline, nontender, no JVD • Eye: Pupils are equal, round, and reactive to light, extraocular movements are intact, normal conjunctiva, vision unchanged • Ears, Nose, Mouth and Throat: Tympanic membranes clear, nasal membranes moist without lesions, oral mucosa moist, no pharyngeal erythema or exudate

  7. Physical Exam • Cardiovascular: Regular rate and rhythm, no murmur, normal peripheral perfusion, no edema. • Respiratory: Lungs clear to auscultation, respirations non-labored, breath sounds equal, symmetrical chest wall expansion • Chest Wall: no tenderness, no deformity • Back: Nontender, normal range of motion, normal alignment Musculoskeletal: Normal strength, no tenderness, no swelling • Gastrointestinal: Soft, nontender, no masses palpated, normal bowel sounds, no organomegaly • Neurological: Alert and oriented to person, place, and time; no focal neurological deficit observed, cranial nerves II – XII intact, normal sensory observed, normal motor observed, normal speech observed

  8. Physical Exam • Lymphatics: No lymphadenopathy noted in cervical or axillary lymph notes. • Psychiatric: Behavior is relaxed, judgment is impaired by abnormal thoughts, and patient demonstrates delusions, tangential thoughts, and flight of ideas.

  9. What are our findings? • Altered 11 year old female:

  10. Differential Diagnosis for AMS • A – Alcohols • E – Epilepsy, Encephalitis, Electrolytes • I – Insulin • O- Opiates, Oxygen • U – Uremia • T – Trauma, Temperature, Thyroid • I – Infection • P – Poisons, Psychogenic • S – Shock, Stroke, Space –Occupying Lesion, SAH

  11. Differential Diagnosis for AMS • A – Alcohol • E – Epilepsy, Encephalitis, Electrolytes • I – Insulin • O- Opiates, Oxygen • U – Uremia • T – Trauma, Temperature • I – Infection • P – Poisons, Psychogenic • S – Shock, Stroke, Space –Occupying Lesion, SAH

  12. What is the rash? • Red raised lesion in right axilla larger one at 2.5X2.5cm with satellite lesions. • This could be about 1,000 things • How does it relate to AMS (is it related at all)?

  13. Differential for Rash and AMS • TTP • Lyme Disease • Syphilis • Meningitis • Steven Johnson Disease • Parasitic Infection • Strep Infection • Varicella • Yeast Infection

  14. Lab Values • BMP:Sodium 137 mMol/L Potassium 3.7 mMol/L Chloride 101 mMol/L CO2 27 mMol/L Anion Gap 9 Glucose 109 mg/dL BUN 6 mg/dL Creatinine 0.44 mg/dL • CBC with Differential: WBC 6.1 thou/mcL RBC 4.2 million/mcL Hemoglobin 12.9 g/dL Hematocrit 38.2% MCV 90.9 FL MCH 30.6 Picograms MCHC 33.8 gm/dL RDW 13.0% Platelet Count 211 thou/mcL 62% Lymphocyte % 27% Monocyte % 11% Eosinophil % 0% Basophil % 0% • Liver Enzymes and Lipase:Alkaline Phosphatase 219 IU/L ALT 33 IU/L AST 20 IU/L Bilirubin Total 0.4 mg/dL Bilirubin Direct 0.1 mg/dL Albumin 4.1 gm/dL Protein 7.2 gm/dL Lipase 106 IU/L

  15. Lab Values • Urine: HCG Qual Negative Color Yellow Appearance Clear Specific Gravity 1.105 pH 6.0 Glucose Negative mg/dL Ketones >80 mg/dLBilirubin Negative Urobilinogen 0.2 unit/dL Leukocyte Negative Nitrite Negative Protein Negative • Urine Drug of Abuse Screen: Negative • Ethanol: Negative • Salicylate: 1.0 mg/dL • Acetaminophen: 0.7 mcg/mL

  16. Lab Results • Mildly Elevated Alk Phos • Mildly Elevated Lipase • Significant Amount of Ketones • Negative Drug Screen

  17. Differential Diagnosis for AMS • A – Alcohol • E – Epilepsy, Encephalitis, Electrolytes • I – Insulin • O- Opiates, Oxygen • U – Uremia • T – Trauma, Temperature • I – Infection • P – Poisons, Psychogenic • S – Shock, Stroke, Space –Occupying Lesion, SAH

  18. Differential Diagnosis for AMS • Epilepsy • Encephalitis • Poisons • Psychogenic • Stroke • Space –Occupying Lesion • SAH

  19. MRI without Contrast

  20. MRI with Contrast

  21. Differential Diagnosis for AMS • Epilepsy • Encephalitis • Poisons • Psychogenic • Stroke • Space –Occupying Lesion • SAH

  22. So Where Are We? • We have an 11 year old female with waxing and waning AMS, abdominal pain, headache, dizziness, history of sore throat, rash, slightly dehydrated with a mildly elevated alk phos and lipase, negative tox screen, negative etoh, no laboratory or clinical signs of infection, and a normal MRI.

  23. Differential Diagnosis • Encephalitis • Epilepsy • Poisons • Psychogenic

  24. Epilepsy • Patient has no evidence that she is experiencing tonic clonic seizure. • Does not appear to be having focal seizures. • Could she be having absent seizures?

  25. Absent Seizures

  26. Encephalitis

  27. LP findings in Encephalitis PCR can be done to detect viral causes.

  28. Poisons • What was that pink pill she was referring to? • Anti-cholinergic • Hot as a hare (hyperthermia) • Dry as a bone (dry skin) • Red as a beet (flushed) • Blind as a bat (mydriasis) • Mad as a hatter (delirium)

  29. Poisons • Sympathomimetic • T – tachycardia • H – hyperthermia • I – increased motor activity • R – restlessness • D – dilated pupils • S - sweating

  30. Poisons • Was it the Pesticide? – Usually carbamates or organic phosphates. • D – diarrhea, diaphoresis • U – urination • M – miosis • B – bronchorrhea, bradycardia, bronchospasm • E – emesis • L – lacrimation • S - salivation

  31. Psychogenic • Diagnosis of elimination. • Other physical complaints occurring.

  32. Differential Diagnosis • Encephalitis • Epilepsy • Poisons • Psychogenic

  33. Autonomic Instability • Dizziness or fainting Yes • Inability to alter HR Not Sure • Sweating Yes • Digestions Difficulties Not reported • Urinary Problems Not reported • Blurry Vision Yes • Headache Yes

  34. Abdominal Pain • Suggested that the abdominal pain be worked up with US as below

  35. Differential Diagnosis • Encephalitis + Ovarian Mass = Anti-NMDA Encephalitis • Epilepsy • Poisons • Psychogenic

  36. Anti-NMDA Encephalitis • New diagnosis first case report 2005. • Typically young woman • Early findings include behavioral changes, memory loss, hallucinations, irritability, sleep disturbances and seizures • Often mis-diagnosed as a psychiatric illness or drug abuse. • Frequently associated with an ovarian tumor. • LP will be positive for anti-NMDAR subunit antibodies in the CSF

  37. Clinical Findings of the disease • Lancet Neurol. 2008 Dec;7(12):1091-8. doi: 10.1016/S1474-4422(08)70224-2. Epub 2008 Oct 11. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. • 100 patients, 91 were woman • All presented with memory loss or psychiatric symptoms • 77 had seizures • 88 had decreased level of consciousness • 86 dyskinesias • 69 Autonomic Instability • 58 had tumors mostly ovarian teratomas • Interpertation - A well-defined set of clinical characteristics are associated with anti-NMDA-receptor encephalitis. The pathogenesis of the disorder seems to be mediated by antibodies

  38. Can an Ovarian Tumor Cause these Symptoms?

  39. Information that would be useful: • What was the pesticide used and onset of symptoms in relation to it. • Rectal Temperature • Skin exam – states her cheeks were flushed and she was dry later reports diaphoresis and axillary exam reporting if she was sweating would have been helpful • Picture of the Rash • More images of US and MRI • Specific tests that were performed on CSF

  40. FINAL DIAGNOSIS Anti-NMDA Encephalitis Secondary to ovarian tumor likely teratoma

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