VA AM Report 5.23.17: Bag o’ Pearls

Credit GJ for the catchy blog title. Today one of our sub-I’s Christina presented a fascinating case of long standing leukopenia/thrombocytopenia along with some neuropathy. We had at least 7 killer pearls so I’m just gonna list them.

#From goop: his own case series of patients admitted for the hated “failure to thrive” diagnosis with gait instability, his most common cause of the dwindles regarding gait and ADL/IADL is painless cervical stenosis(!!!) Other dx that pop up more rarely: early Parkinson dz, ALS, myasthenia gravis

#From LT: In the days prior to . . . NSAIDS? just kidding, patients with ankylosing spondylitis used to get radiation therapy to the spine/pelvis! It worked really well for the pain and progression, but unfortunately the bone marrow in the pelvis took a hit and there are some case series of weird hematologic malignancies arising in these patients 20-30 years after treatment. Worth asking about in your older adults w/ unexplained cytopenias.

#The two-minute hyperthyroidism exam: Credit Dr. Elizabeth Murphy, master clinician at ZSFG for this one. The diagnosis of Graves dz can be made with the exam and positive antibodies, precluding the need for radiouptake of Iodine in the dx workup. The presence of exophthalmos, a thyroid bruit and enlarged thyroid, are specific to the dx of Graves disease. Other things to look for in general, an enlarged painful thyroid argues for an acute thyroiditis, tremor, warm sweaty skin, and overly brisk reflexes.

#All comers, most common cause of elevated MCV and anemia is underlying myelodysplastic syndrome. however MCV > 110 are less likely to be MDS and point more toward megaloblastic anemias aka B12/folate.

#Sometimes patients with reported gait instability can correct their deficit when completely focussed on the task, such as when we ask patients to walk while we watch. Always helpful to watch your patient walk to/from the waiting room, or have them do a task while walking or standing. This attentional instability can point to progressive loss of proprioception or a progressive sensory neuropathy.

#Elevated B12: Rule out exogenous B12, but can also see in acute hepatocellular destruction such as ALI or acute viral hepatitis, long standing think of hematologic malignancy namely the myeloproliferative disorders. LT points out the mechanism, increased expression of and production of transcobalamin which then binds more B12, the assay picks up all B12 not just free B12.

#Greg mentioned POEMS toward the end: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin findings. File this under your plasma cell dyscrasia heading. Rare, but in our patient w/ long standing undetectable TSH, polyneuropathy, it came up. Dx criteria (don’t memorize you nerds, keep it on file) are attached below. Thanks gang!

TABLE

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One thought on “VA AM Report 5.23.17: Bag o’ Pearls”

  1. merci mille fois, j’ai du éviter de justesse la restauration grâce a cet article mille merci. ça marche l&;oqusrastuce à merveille.mon ipad2 reboutait sans cesse après installation d’un plu-gin cydia, maintenant j’ai supprimais ce dernier après avoir rentrer en mode sans échec (Appuis sur + au démarrage)

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