Thank you Saundra for presenting the case of an elderly woman with hx of lipodermatosclerosis and psoriatic arthritis on methotrexate p/w bilateral LE erythema, swelling and pain found to have pancytopenia. We had a wonderful discussion of mimickers of bilateral LE swelling and ddx for pancytopenia. There was concern that her methotrexate was driving the presentation and after holding this medication + vitamin supplementation her lines recovered!
- Cellulitis is rarely bilateral! Stasis dermatitis is one of the most common mimickers. See this article for ddx of mimickers.
- A chronic course points to something other than cellulitis (tempo as usual is always important in history).
- Approach to pancytopenia can be broken down into peripheral destruction or degreased production (remember the garden!!). See more details below.
Ddx for bilateral LE Swelling and Erythema
- Venous stasis
- Contact or stasis dermatitis
- Nutritional deficines – zinc, niacin, vitamin C
- Lymphedema or Clot – more likely central
- Obstruction – lymph, venous or arterial
- Pretibial myxedema (Grave’s disease)
- And finally…Cellulitis
Approach to Pancytopenia
Bone Marrow Infiltration/Replacement
- Malignant: Leukemia, Multiple Myeloma, Metastatic Cancer
- Non-Malignant: Myelofibrosis, Infectious (TB, MAC, histo), Storage disease
Bone Marrow Failure
- Immune destruction/suppression
- Aplastic/PNH, Medications (methotrexate), HLH, SLE, RA
- Nutritional: megaloblastic, alcohol excess, copper/zinc
- Marrow Suppression: HIV, EBV, CMV
- Ineffective hematopoiesis: MDS, nutritional
- Congenital failure: Fanconi syndrome
- Consumption: DIC, APML, Sepsis
- Splenomegaly: portal HTN, infectious, lymphoma,
HH told us about an elderly woman originally from China admitted with weight loss, decreased PO intake, found to have a complex cecal mass that had grown in size over 6 months. Colin also shared with us an image of a young woman with lupus who’s CT scan showed a target sign.
Not all ileocecal masses are cancer! Here’s a brief approach to the DDx for a cecal mass:
- Primary colorectal cancer
- Carcinoid tumor
- Cancer mimics
- Mycobacterial: TB
- Bacterial: Yersinia, salmonella, actinomyces
- Fungal: histoplasmosis
- Parasitic: entamoeba histolytica
The “target sign” is a CT imaging finding resulting from enhancement of mucsa and muscularis propria with the edematous submucosa in between.
DDx for Target Sign on CT scan
- Crohn’s disease
- Radiation enteritis
- Ischemic bowel
- Intramural hemorrhage
- Vasculitides such as HSP
- Pseudomembranous colitis
Thank you, Tim, for presenting a few mini-cards cases and ECGs! The first was a middle-aged woman who experienced acute onset of chest pain associated with nausea, vomiting, and an episode of diarrhea. Thank you, Salman, for presenting a young man who was found down following seizure and noted to have bi-directional VT.
- Myocardial ischemia can present atypically in certain patient groups, particularly women, elderly, and diabetics. We also learned from Anne Thorson that women tend to present to medical care with their anginal chest pain later than men
- Below, see a chart showing the clinical presentation of acute MI according to age, published back in 1986, and reviewed by Ochiai et al. in 2014.
- DEPRESSION in anterior leads suggests possible POSTERIOR elevation – and should warrant getting posterior leads (V7-V9)
- Ticagrelor is a newer antiplatelet agent that has been shown to have improved outcomes compared to clopidogrel. Best used within 7-10 days after an MI. However, has increased risk of bleeding and is MUCH more expensive than clopidogrel.
- In a meta-analysis by Angiolillo et al. published this year, patients who de-escalate from ticagrelor to clopidogrel have a 1.4% rate of major adverse cardiovascular events, with a 1.3% rate of stent thrombosis, paralleled by a 0.04% rate of major bleeding.
- Bidirectional VT is associated with certain toxicities and a limited list of genetic predisposition
- Digoxin overdose – most commonly described
- Aconite toxicity – aconite is an herbal supplement. When prepared incorrectly, can result in poisoning. There was a series of overdose cases here in the bay area in March 2017.
- CPVT – familial cathecholaminergic polymorphic ventricular tachycardia
- Mutations in either the RYR2or CASQ2 gene disrupt the handling of calcium within myocytes.
- During exercise or emotional stress, impaired calcium regulation in the heart can lead to ventricular tachycardia in people with CPVT.
- We reviewed the clinical manifestations of IgG4 disease, including commonly associated findings such as pancreatitis, sialadenitis, and lymphadenopathy as well as the many other manifestations (see more details below!). In general, one or multiple organs can be involved. Lymphadenopathy and subacute development of a mass in an affected organ are common. Diagnosis is often delayed.
- The DDx of a pancreatic fluid collection includes 3 main things:
- Walled off pancreatic necrosis
- Management of pancreatic pseudocysts is generally to LEAVE IT ALONE! Reasons to consider drainage include persistently large size (usually >5cm), significant mass effect (regardless of size), superinfection, and concern for underlying malignancy. Check out this table from The Journal of the Hepatic Pancreatic Biliary Association.
IgG4-associated conditions (adapted from UpToDate)
||Autoimmune pancreatitis, pancreatic masses
|Dacryoadeniitis and sialadenitis
||Inflammatory orbital pseudotumor
|Midline destructive disease
||Chronic sclerosing aortitis and periaortitis
|Pulmonary inflammatory pseudotumors
Diagnosis of IgG4 disease is depending on BIOPSY. While IgG4 levels can be informative (and absolutely should be checked!), you really need to see pathology with the classic lymphoplasmacytic tissue inflammation of IgG4-positive plasma cells and lymphocytes with accompanying storiform fibrosis. Even the pathology, however, can at times be nonspecific, looking quite similar to other conditions such as some malignancies, granulomatosis with polyangiitis, and Castleman’s diseases to name a few.
For more info, check out this NEJM review, and this Lancet review about IgG4 disease – both have great clinical images of the dacryoadenitis and sialadenitis!
IgG4 Evernote: https://www.evernote.com/shard/s462/sh/26c723e2-ce6d-4c4c-b525-1163cd555326/fe0c6f5b2076fc5952cda14b54ed417a
Pancreatic Pseudocyst Evernote: https://www.evernote.com/shard/s462/sh/50665d72-3b5d-44db-8749-0ef82f8457da/1d5129c97dbf2b84bdfcd8bbd1768cee
Thank you Satvik for presenting at renal report! We heard about an elderly man with ESRD on PD presenting with epigastric pain and mild nausea, concerning for peritonitis.
- Diagnostic cut-offs for peritonitis in patients with PD differ from other patients. This is for 2 reasons – (1) the pretest probability is generally higher, so we want more sensitivity and (2) the abdominal cavity is diluted by PD fluid, so a lower concentration of cells is still be very concerning.
- Cut off >100 WBCs or >50% PMNs
- positive gram stain or cultures (though MANY are culture negative)
- Peritonitis is a common and serious complication of PD. While less than 5% of PD related peritonitis cases result in death, peritonitis is a major contributor of death in ~16% of PD patients!
- Antibiotics in PD peritonitis warrant coverage of both gram positive and gram negative organisms! Current recommendations are:
3rd generation cephalosporin
- PD catheters can usually be salvaged in peritonitis. However, in certain infections, it needs to be fully removed.
- fungal infections
- recurrent infection
References: ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment: http://www.pdiconnect.com/content/36/5/481.full
Thank you to the great Sam Brondfield for joining us AND presenting a fascinating case! We discussed an older woman with metastatic lung adenocarcinoma on erlotinib transferred from OSH with shock with markedly elevated uric acid, LDH, and renal failure.
- Erlotinib is an EGFR inhibitor and used in the treatment of metastatic lung adenocarcinoma with positive EGFR mutations. In general, these medications are tolerated very well. The primary side effects experienced include folliculitis and diarrhea. See below for more details about specific lung cancer mutations.
- Not all cancers have equal bleeding risk. Guidelines suggest avoiding anticoagulation in patients with RCC, melanoma, choroid germ cell, and medullary thyroid cancer if they have brain metastases as they are at high risk for intracranial hemorrhage.
- Lung cancer is the only cancer for which guidelines recommend brain imaging as part of the initial screening (in patients with metastatic disease or any patient with small cell lung cancer).
- 5% of lung adenocarcinomas can transform into small cell lung cancer. Small cell cancers are a subset of neuroendocrine cancer, and can arise from multiple types of cells. We are most familiar with discussing small cell lung cancer, but this is also seen in the setting of prostate cancer.
Lung Cancer Targeted Treatment
There has been great progress over the years in treatment of lung cancer. We now routinely test for a variety of specific mutations in metastatic lung adenocarcinoma and in squamous cell carcinoma. See the pie chart below for a breakdown of the various known mutations. Many of these now have targeted therapies. This image comes from the Lung Cancer Initiative, a great resource that also outlines the various treatments to target distinct mutations.
Refresher on the Etiologies of Shock
- Adrenal insufficiency
- Hypovolemic/Hemorrhagic (crystalloid vs. blood)
- Abdominal compartment syndrome
Spontaneous Tumor Lysis Syndrome
Check out this case series and review of TLS in small cell lung cancer. This is a rare, but highly morbid complication of small cell lung cancer. While TLS is more commonly seen in hematologic malignancies, namely Burkitt lymphoma, AML and ALL, there are reports in the literature of its association with various solid tumors.
Lung Cancer Evernote: https://www.evernote.com/shard/s462/sh/afabb27e-bf47-4a37-8548-0d42a1446095/21d37a9b6aa898f608605eefbc9e1c40
Thank you to Armond for presenting a case of a elderly man with AF and Parkinson disease presenting with exertional syncope found to have a depressed EF and cath showing 95% LAD occlusion.
- When working up a patient who presents with syncope the history is the most important diagnostic tool.
- Concerning features suggestive of cardiac cause include syncope with exertion, lack of prodromal symptoms, and trauma.
- After syncope from ANY cause you may see myoclonic jerks 2/2 to global anoxia of the brain. See this video for an example of healthy medical students with induced syncope and subsequent myoclonic jerks. https://youtube.com/watch?v=YaktxCXiUyY
- We define Ventricular Tachycardia as > or = 3 VPCs at rate of at least 100. Sustained VT is > 30 seconds or VT with hemodynamic compromise. Non-sustained VT is < 30 seconds.
General Approach to Syncope
- Structural: chest pain, dyspnea, exertional, post-operative
- Arrhythmia: sudden syncope, injury, palpitations
- Reflex Mediated
- Vasovagal: warmth, nausea, prodrome, tunnel vision
- Situational: occurs after certain activity (micturition, cough)
- Neurocardiogenic: Provocable stimulus
- Carotid sinus hypersensitivity
- Orthostatic Hypotension
Clinical Features Suggestive of VT
- Age > 35 (positive predictive value of 85%)
- Structural heart disease!!
- Previous MI or hx of ischemic heart disease
- Congestive heart failure
- Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT)
- WHEN is doubt shock it out!!
Thank you to Michelle Mourad for this educational slide from last week’s awesome M@M.
Syncope Evernote: https://www.evernote.com/shard/s462/sh/9c271d40-2562-48c1-9bd1-cb6f54179d73/33f49d97647c6e61252807c98013e7dd