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Thursday, June 18, 2009
Day #343 - Interstitial Lung Disease
Today we presented a challenging case -- where Occam's Razor again met head to head with Hickam's dictum.
The discussant began by talking about the various rheumatoid manifestations in the lung.
We then honed in on interstitial lung disease (previous blog on IPF here), and discussed the phenomenon of acute exacerbation of ILD (other review on non-IPF related AE-ILD here) -- a relatively new concept in respirology.
We also talked about the possibility -- and confirmation -- of pulmonary embolism. Noting of course that PE would not explain the diffuse ground glass opacities.
We discussed the possibility of a superimposed community acquired pneumonia, or TNF-alpha associated granulomatous infection and the need for treatment of same.
Tuesday, June 16, 2009
Day #341 - Likely TB Pleural Effusion
Monday, June 15, 2009
Day #340 - Occular Myasthenia
The JAMA rational clinical exam series addresses the physical diagnosis of MG here.
History:
"speech becoming unintelligible during prolonged speaking" LR 4.5
presence of the peek sign increase the likelihood of myasthenia gravis LR 30 (eyes "peek" open within 30 seconds of closure)
Bedside Tests:- Ice test LR + 24 LR - 0.16
(apply ice to the eyelids x 2 mins then evaluate response which should be immediate and short-lived) - Response to an anticholinesterase medication LR+ 15 LR - 0.11
(give tensilon, look for response within 30 seconds lasting less than 5 mins) - Sleep test LR+ 53.0; LR - 0.16
(have patient lie in a dark room resting the eyes for 30 mins, look for improvement of ptosis)
A discussion of myasthenia mimics is available here.
Friday, June 12, 2009
Day #337 - Cirrhosis (PBC)
Given the markedly elevated ALP with no bony symptoms and normal ducts on the ultrasound, we proposed a diagnosis of Primary Biliary Cirrhosis (see review here).
See the associated review/editorial on cholestatic liver diseases from a prominant Toronto hepatologist here.
I have also provided a link to a review article on Hepatitis C and HIV co-infection, since it was discussed and is relevant. There is some evidence that HAART may actually worsen the liver disease in these patients and that perhaps the HCV needs to be treated.
Thursday, June 11, 2009
Day #336 - Terminal Illeitis and Abscess
Wednesday, June 10, 2009
Day # 335 - Severe Influenza
Monday, June 8, 2009
Friday, June 5, 2009
Day #330 - HSP
They presented with a prodromal URTI (more common in patients younger than 30) and then:
- Lower extremity purpuric rash (picture here)
- Abdominal pain with or without gastrointestinal bleeding (GI manefestations reviewed here)
- Symetrical arthritis of the large joints in the lower limbs
- Macroscopic hematuria with the development of renal failure and nephrotic syndrome
Poor prognostic signs include:
- Creatinine more than 120
- Proteinurea more than 1g/day
- Fibrosis or necrosis on kidney biopsy greater then 10%.
The major differential of purpuric skin rash and macroscopic hematuria includes drug-induced hypersensitivity vasculitis, which usually has a good prognosis and cryoglobulenemic vasculitis, which has a much worse prognosis.
If you speak german, I think this is schonlein's book from 1832 where he first describes this condition.
I've been on a medical history theme this week -- here is an article from 1914 by Osler on HSP.
Thursday, June 4, 2009
Day #329 - Fever of Unknown Origin
Today we discussed a patient with fever of unknown origin (previous blogs here including links to the articles I mentioned)
I erred when I said that abdominal imaging was required prior to making the diagnosis -- however, given the ease at which we can get said imaging I would say that it probably *should* be required before labeling as FUO. Certainly, it should be the first test performed in the "second tier"
On the basis of profound inflammatory markers and microscopic hematuria (in the absence of other causes) I postulated that this case may be a medium-small vessel vasculitis such as microscopic polyangiitis. A classic NEJM review on small vessel vasculitis is available here and the corresponding article on medium vessel vasculitis is available here.
This article reviews the guidelines for the management of medium and small vessel vasculitis.
Wednesday, June 3, 2009
Day #328 Cushing Syndrome
- Confirm cortisol excess. 24h urine cortisol or the 1mg overnight dexamethasone supression test are the best in terms of sensitivity and specificity.
- Is the ACTH high? If yes proceed to evaluate for adrenal adenoma or ectopic ACTH. Is ACTH low? Look at the adrenals.
ACTH High (see original publication by Hurst -- former faculty @ Toronto (memorial tribute here) from 1928 lancet)
From the diagnostic algorithm article: "A woman with mild to moderate hypercortisolism, a normal or slightly elevated plasma ACTH, and normokalemia has at least a 95% likelihood of having Cushing’s disease. In contrast, a patient with prodigious hypercortisolism, hypokalemia, and marked elevations of plasma ACTH may be more likely to have an occult ectopic ACTH-secreting tumor. "
Pituitary MRI is the next step:
Adenoma -- likely not ectopic ACTH (above) = resect
No adenoma, or likely ectopic ACTH = more evaluation
The 8mg dexamethasone suppression test is not sensitive or specific.
Petrosal sinus sampling with CRH stimulation is the best diagnostic test, but is invasive.
If ectopic ACTH confirmed:
bronchial, thymic carcinoids or other neuroendocrine tumors (e.g. islet cell, medullary carcinoma of the thyroid, or pheochromocytoma)
CT thorax and abdomen may find the tumor. If negative consider octreotide scan. Sometimes you won't find it.