Day #264 Sickle Cell Anemia

Today we discussed a patient with sickle cell anemia (previous blogs) who presented with acute onset chest pain, bilateral chest xray infiltrates and profound hypoxemia.

This patient had a compound heterozygote of sickle and beta-thalassemia. A review of the various compound heterozygotes is available here.

This patient may have had chest crisis. We did not see the initial xray. The definition of acute chest crisis/syndrome:

• New Chest Xray Infiltrate with chest pain
  AND


• One of: cough, fever, hypoxemia, tachypnea, sputum

A review of the ACS is available here. A more detailed review of the pulmonary complications in sickle cell anemia is available here.

We discussed red cell exchange (review here) which should be considered in ACS.

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The patient also complained of crushing retrosternal chest pain with a new left bundle branch block on the ECG. This turned out *not* to be myocardial ischemia; although this was diagnosed retrospectively. Interpreting STEMI in the context of LBBB is difficult. This article discusses the relationship of bundle branch block to MI and suggests means of diagnosis that are relatively specific but not sensitive.

A further meta-analysis is available here.

Clearly we need to do better at picking up ischemia in the context of LBBB. I suggested that a STAT echo may have been helpful in this case in picking up LV dysfunction which would be expected with an ischemic LBBB. This is in keeping with the recomendations of the American college of cardiology.

Day #263 - Hemoptysis

Today we discussed a patient with previously resected lung cancer who presents with new onset worsening of hemoptysis. We've previously discussed haemoptysis here .

This case subsequently turned out to be a pulmonary hemmorhage syndrome (Churg Strauss) with glomerulonephritis. There is a good case report in the NEJM here. There is another case in NEJM here as well.

The original case description is available here.

A review on pulmonary vasculitis here.

Day #259 - Hepatic Encephalopathy

Today we heard about a case of a man who presented with acute hepatic encephalopathy of multiple possible etiologies including substance withdrawal and probable GI bleeding.

We reviewed the complications of nasogastric tube insertion.

I have blogged extensively on cirrhosis and its complications (and treatment thereof) previously (here, here, here, and here)

Previous blogs on upper GI bleed here and here.

Day #258 - Meningovascular Syphilis

Today we heard a case of a young man with headache and diplopia who rapidly went on to develop ischemic brain lesions and progressive deficits.

I have blogged about diplopia here.

The final diagnosis was meningovascular syphilis. The discussant also described the natural history (or stages) of syphilis as I have covered here.

Day #257 - Viral Encephalitis

Today we heard the story of a young woman with fever, headache, photophobia, and confusion/drowsiness with a normal CT and an LP with a lymphocytic pleocytosis with elevated protein. The presumed diagnosis was viral meningoencephalitis and she was treated with IV acyclovir.

Despite excellent data on bioavailability, there are only case reports of substituting oral valacyclovir for IV acyclovir in the treatment of HSV encephalitis. This would be an interesting option which would decrease the need for IV in patients who recovered after IV "induction". It is biologically plausible because the levels in the plasma achieved by valacyclovir approximate acyclovir without the concomittant nephrotoxicity. Apparently clinical trials are underway.

We have previously blogged about HSV encephalitis here.

Day #256 -Pleural Effusion/Congestive Heart Failure

I have previously blogged about the approach to pleural effusion here.

We reviewed some general causes of:

Exudate:

• Malignancy
• Infection
  
  • Parapneumonic
  • Empyema
  • TB
  • Subdiaphragmatic abscess
    
• Inflammatory
  
  • SLE/RA/FMF
• Pulmonary Embolism
  
• Hemothorax/Chylothorax

Transudates:

• CHF
• Cirrhosis (including sympathetic)
  
• Nephrotic Syndrome
• Malnutrition
• Hypothyroidism

I have previously discussed congestive heart failure here (link to guidelines there as well).

A summary of the class I recommendations:

• Moderate salt restriction in the diet with daily weights
• Exercise testing and exercise programme
• Stop offending medications (i.e. NSAIDS, most calcium channel blockers)

• Diuretics (e.g. furosemide) as required to keep euvolemic
• ACE inhibitor such as lisinopril, enalapril, ramipril, etc. as tolerated. ARB in patients who are intolerant of ACEi due to cough
  
• Beta-blockade with beta-blocker proven to influence outcome in CHF. Start slowly, when euvolemic, with very slow titration in advanced HF (e.g. carvedilol, bisoprolol)
• Consider adding digoxin (see dosing here) to improve symptoms and decrease hospitalization.
• Consider adding spironolactone in patients with NYHA III/IV symptoms and LVEF less than 35% to ACEi or ARB if Cr less than 150 and K+ less than 5 and you can monitor potassium and renal function. Caveat publication here.
  

Assessment of revascularization and modification of the cardiac risk factors is also important.

When he is no longer NYHA IV, and he is on MAXIMAL medical therapy, and he is expected to live more than one year, he can be considered for an ICD (Ischemic Cardiomyopathy with EF less than 35%) for primary prophylaxis of arrythmogenic death.

An article discussing LV thrombi in the context of ischemic cardiomyopathy is available here.

Scenario - Pericarditis

Examples of ECGs of the 4 stages of pericarditis are here.

• Stage 1: Diffuse concave ST elevation with PR depression
• Stage 2: PR depression only with pseudonormalization
• Stage 3: T wave inversion
• Stage 4: Normalization

Good review in NEJM here. A further review on the use of colchicine in the treatment of acute and recurrant pericarditis is available here.