Good case.

[Hotsauce21]

A case that came in today.

HPI: 66 year old Complaining of worsening left sided chest pain, worse with inspiration, plus some SOB. Also, has chronic leg pain, and diffuse body pain. CP is reproducible with palpation across entire chest. Has diffuse abdominal pain as well, worse with palpation. Is wheechair, walker bound, having trouble getting in/out of bed. Mildly decreased stool output, last one yesterday. Increasing lower extremity edema despite lasix.

ros: no f/c. no n/v. no bloody stools.

Past Medical History: morbid obesity, s/p gastric bypass, first1994. Lost 200 lbs afterwards. Revision in 2003 (b/c was gaining weight back) Lost another 65 after operation. Chronic diffuse pain started roughly after 2nd surgery. On fentanyl patch 100 for months, then recently to 150.

Admitted 4 mo ago OSH for Increased LE swelling. Also repeatedly transfused, although she doesnt know why. No melena or GIB. No cause for edema found, put on Lasix. She's having worsening LE edema despite lasix. Neg dopplers previously.

Had normal adenosine stress recently. EF 85%. Echo previously normal. CT scan previously showed severe osteomalacia of pelvis, likely insufficiency fractures. mild intra/extra bil dil, pancreatic duct mild dilated, unclear significance. seen recently by PCP, though diffuse pain due to osteomalacia, put on CA/Vit D. and checked Vit D levels, PTH, caPTH.

Home Medications: Lasix, Zelnorm, Prevacid, docusate, Vicodin and
fentanyl patch.Also, put on bactrim recently for uti. no known g6pd. sulfa allergy.

Allergies: PCN, codeine, Talwin

Exam: 89% ra. hr 80's bp ok. afebrile. 140 lbs.
african american female, shaky, able to converse, in wheelchair, but in pain when moves. slightly overweight. heent benign. cv: 1+/6 sem at apex. chest clear. diffuse chest, abd. pain to palpation. no murphys. no organomeg. 2+3+ le edema. good pulses

Labs: 1,25 oh vit d level, vit d3 levels almost unmeasurable
caPTH normal. PTH increased
serum ca 8.3 alb 2.7 ast/alt 30's tbil 1.7 alk phos 300
inr 1.0 wbc 12.2 h/h 7.8/23 down from 11/33 previously.
DAT neg.
haptoglobin 1 ldh 313.
ftn 2390
tsh 2.7
troponins neg x 2
ua + nitrite, 5 wbc's/hpf, 5 rbc's/hpf
bnp 23

EKG nsr
AAS: nonobstructed bowel. old pubic rami fx.

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[CCMD2005]

Could this be Paget's Disease, generally see elevated Alk phos w/ normal Ca and Pth...However, with Gastric Bypass, calcium absorbtion could be decreased if she had Bilroth I or II (calcium absorbed in proximal Small Intestine and distal small intestine does not "make up" for this loss).
-CC

 

[in4mthsMD]

Musculoskeletal chest pain, Spontaneous Pneumothorax vs PE comes to mind. However, I want to know what is causing her abdomen to hurt. SHe is afebrile right? Was she ever febrile in recent days? Chest pain with inspiration suggests Pericarditis, PE or Spontaneous Pneumothorax.. Pls let me know how it turns out,okay? I need to take a look at the labs once more.

 

[Hotsauce21]

more updates soon. as i find out.

 

[souljah1]

An eldery woman s/p gastric bypass surgery c/o diffuse bony and abdominal pain with reproducible chest pain with palpation who on exam if found to have a mild flow murmur (most likely 2/2 anemia), diffuse abdominal tenderness, and bilateral lower extremity edema.

Pt has a low albumin with a normal corrected calcium, as well as low 1,25-OH2-D levels (this is not the storage form of vitamin D, 25-OH-D is) and increased PTH. She has an anemia, but the reticulocyte and MCV are unknown, as is the possibility of GI bleed (guaiac??). LDH is not specific for hemolysis, but with a crit drop this could be a possibility. The isolated alk phos elevation is likely secondary to bone resorption (increased PTH) and much less likely due to a hepatic process.

My concern for her would be for malnutrition secondary to gastric bypass/revision. Most of these patients have to be vigilent in their intake of vitamins (both fat soluble and water soluble). Increased PTH with a low Vit D level suggests the possibility of poor vitamin D absorption and secondarily calcium malabsorption (although corrects to normal, likely due to increased PTH). Increased bony resorption leading to diffuse bony pain??? Vitamin K can be low in bypass patients as well, but it is more difficult to achieve a vitamin K defic and her INR is normal. Her albumin is low, which is possibly due to poor protein intake, but in general is occurs with an negative acute phase response. An albumin this low could be responsible for her lower extremity edema in the phase of chronic venous insufficiency (common in the obese). Her crit drop could be due to poor B12, folate, Fe (would love to know a retic and an MCV).

What kind of bypass did she have? B12/MMA? RBC-folate? TIBC? ferritin? 25-OH-D? Platelets? Was she taking any vitamins? Normal diet?

I just like the possibility of malnutrition b/c it can explain quite a few of her symptoms (not quite a razor). Can't really think of any one disease to explain her presentation. I guess when any African American patient presents with diffuse body pain along with chest pain you have to consider Sickle Cell disease, but this would be a fairly atypical presentation.

Thanks for posting this. Looking forward to finding out more information and hearing from some others.

 

[Hotsauce21]

heme update:

mcv 109 rdw 17
retic 5.83%, LDH 313, haptoglobin 1, unconj bili 1.2, iron 67,
ferritin 2390, fibriniogen 355, d-dimer 1.9

also, recieved blood transfusion age 9. has received b12, iron since her bariatric surgeries.
no problems or transfusions needed until needed 4 transfusions in august, and nearly monthly afterwards. told she doesnt have "hgb s, but may have "c", but apparently, no one gave her a firm diagnosis, basically said "they didnt know"

possible family history of females in her family with anemia, but noone has needed transfusions, or splenectomy, to her knowledge. aka no ss dx as far as she knows.

also, she has been taking a large amount of tylenol at home, possibly toxic amounts, but not mammoth amounts.

 

[souljah1]

Looks like malabsorption is unlikely.

So a hyperproliferative anemia with an MCV of 109 could be marked reticulocytosis secondary to hemolysis (increased LDH, decreased haptoglobin, elevated tbili --> indirect??) seen with hemoglobinopathies, autoimmune hemolytic anemias, or less likely MAHA/destructive processes. The reticulocyte % is not crazy high though. The bony pain and chest pain could also make sense with sickle cell disease. Positive female family history is a little odd being that it is autosomal recessive.


Smear?
Gel Electrophoresis?

 

[doc05]

Please describe the abdominal exam in greater detail. By now you've probably gotten a CT of the abdomen, or at least a RUQ sono. what about CXR??

Get a better history of what type of surgical procedures were done - both the initial and revision surgeries. There are about a dozen types of "gastric bypass."

Was a guaiac done?? What was the result??

And this is not sickle cell disease. Remember that her h/h was down from 11/33; you don't see that w/sickle cell. Even if she's HbSC, this presentation is unlikely.

Elevated MCV is seen with folate deficiency, which isn't common, but does occur.

Souljah's latest comments do bring a few questions of my own...fractionated bilirubin? peripheral smear? WBC differential?? Maybe CLL?

 

[souljah1]

doc05,

You could have a crit of 33 if you are getting transfused at the rate that is stated. True, sicklers on their own usually run 20-30, but 33 isn't all that difficult to imagine. She kind of looks like she has a hemolytic picture. The MCV could be explained by the fact that she is retic'ing. You crit rises for every unit of PRBC you get, so it would be all that hard to imagine your crit going from say 28 to 33 if you've gotten a unit (atleast) monthly.

For CLL, any LAN? Hepatosplenomegaly? Her WBC is only 12,000. Usually in CLL it would be atleast 20,000.

 

[Hotsauce21]

previous surgeries: gastric exclusion procedure 1994 (prox. jejunal anastamosis), hysterectomy, exploratory surgery (adhesions lysis), tummy tuck,celiac plexus block for previous chronic abdominal pain and an umbilical hernia repair, and chole.

had an EGD years ago which said "The stomach was entered and closely
examined. The antrum, angularis, lesser curve, greater curve, pylorus, and a
retroflexed view of the cardia and fundus were performed. The
duodeum was entered and the bulb and sweep were inspected. Except for findings as noted, the esophagus, stomach, pylorus, and duodenum were normal.

1) Anastomosis was noted in the proximal jejunum. The patient is
s/p exclusion gastric bypass.The scope was passed 80 cm into proximal
jejunum.No abnormalities found.

Also, colonoscopy was normal except for diverticulosis.

smear: schistocytes, bite cells. also macro shows poikilocytosis, anisocytosis, consistent with transfusion.

cant get a gel electrophoresis because she just got transfused, thats what heme says. she appropriately bumped after 4 u prbc's.

her abdominal exam apparently is "muliple well healed scars. slightly tympanic to percussion; no palpalbe hepatosplenomegaly. discomfort with deep palpation upper abdomen diffusely, no rebound".

the other note says "ntnd, nabs" (lol)

also, uncon bili 1.2 conj. 0 guaiac negative (i believe)
cxr was normal.

still has chest pain, head, leg pain, and back pain

Looks like malabsorption is unlikely.

So a hyperproliferative anemia with an MCV of 109 could be marked reticulocytosis secondary to hemolysis (increased LDH, decreased haptoglobin, elevated tbili --> indirect??) seen with hemoglobinopathies, autoimmune hemolytic anemias, or less likely MAHA/destructive processes. The reticulocyte % is not crazy high though. The bony pain and chest pain could also make sense with sickle cell disease. Positive female family history is a little odd being that it is autosomal recessive.


Smear?
Gel Electrophoresis?

 

[rennairda]

third year at U of Mississippi -- see lots of SS, SC, S/beta thal here -- it would be very unlikely for a patient to survive to age 66 with a serious hemoglobinopathy -- survival into 50s is remarkable -- and patient would almost certianly have extensive history of hospitalizaion for pain crisis

How is her renal function? Lasix is only effective if kidneys are being effectively perfused and failure to convert absorbed vitamin D to active form could explain some of this presentation;

Also like malabsorption/malnutrition in the Ddx, wondering a bit about the 85% EF?

tough case

 

[souljah1]

rennairda,

Great point about her age and lack of extensive hospitalizations.

Do you agree that her anemia seems partially due to hemolysis based on the labs provided? I wouldn't expect an increased reticulocyte percentage with malabsorption-related anemias or other myelosuppressive processes. Retics could be up due to a bleed as well, but the history is poor for a bleed.

To the poster: how about a little better history. Has she ever been hospitalized for similar pain before? SOB chronic or acute? progressive or intermittent? More about her family members requiring transfusions. How long has her pain been bothering her? Any relation to the surgeries she had or has her pain been a problem for longer? Also, how about a chem10, cbc w/ diff, reticulocyte count (in addition to percentage), coombs, and abdCT??

 

[Hotsauce21]

She was hospitalized in december for chest pain, and had normal stress. ef 85%. also had echo, normal, nothing mentioned about diastolic dysfunction. admitted for a day, with neg troponins, stress, and discharged with diagnosis of noncardiac chest pain.

she was admitted also in august for worsening lower extremity edema, as was mentioned above, had 2 week stay requiring 4 blood transfusions, negative cardiac workup, and needed one blood transfusion monthly since.

As for her shortness of breath, that is a minor complaint. She is saturating well on room air. Also, had an abdominal CT within last few weeks, with results as stated in first note. The character, intensity of her abdominal pain has not changed so they are not going to repeat.

she definitely has chronic pain, especially abdominal pain. relates this to previous abdominal surgeries, adhesions, etc. apparently has had previous surgeries/laps, lysis of adhesions, but dont think any in past year. she has had celiac nerve block in the past as well, which apparently didnt resolve all her pain. It is very difficult to understand her pain, this would be an "acute on chronic exacerbation of pain" with more chest/back pain than usual abdominal pain. There is certainly some psychologic component. How much, is difficult to say.

b12 >1200
Folate RBC mildly high
G6PD normal (after transfusions)
Ddimer, fibrinogen normal
amylase 185 lipase 5
DAT (mentioned before) = Coombs and was negative

Retic 6.2% (HIGH)
WHITE BLOOD CELL COUNT (WBC) 9.3 4.0-10.0 K/MM3
HEMOGLOBIN (HGB) 11.1 L 12.0-16.0 G/DL
HEMATOCRIT (HCT) 32.7 L 35.0-48.0 %
PLATELET COUNT (PLT) 201 150-450 K/MM3
MCV 99
RDW 21

DIFFERENTIAL:
SEGMENTED NEUTROPHILS (SEGS %) 64 40-70 %
BANDS (BANDS %) 0 0-15 %
LYMPHOCYTES (LYMPHS %) 22 20-50 %
MONOCYTES (MONOS %) 9 H 3-8 %
EOSINOPHILS (EOS %) 1 0-4 %
BASOPHILS (BASO %) 0 0-2 %
METAMYELOCYTES (META %) 4 H 0-0 %
MYELOCYTES (MYELO %) 0 0-0 %
PROGRANULOCYTES (PROGRAN %) 0 0-0 %
BLASTS (BLASTS %) 0 0-0 %
NUCLEATED RBC (NRBC) 5 R
POLYCHROMASIA (POLY) 3-5 /HPF *
SCHISTOCYTES (SCHISTOCYT) 1-3 /HPF *
MISC: (MISC SIDOCYTS *

SODIUM (SOD) 132
POTASSIUM (POT) 4.9
CHLORIDE (CHLOR) 103
CO2 (CO2) 26
UREA NITROGEN (UN) 23
CREATININE (CREAT) 0.9
GLUCOSE (GLUC) 89
CALCIUM (CAL) 7.9

Cryoglobulins, Cold agglutinins, ANA, HIV, HCV pending

 

[carol ann]

an ef of 85% IS NOT NORMAL

 

[Hotsauce21]

87% is the ef from an adenosine thallium. co was 4.1 0% stress defect in all territories.

tte showed ">55%ef, normal chamber sizes, wall motion." no mention of E/A ratio. of note, lv mass 108 grams, which is normal. (unless erroneously reported as grams and not g/m2) Also, LA size only 25 mm

an ef of 85% IS NOT NORMAL

 

[Pili]

87% is the ef from an adenosine thallium. co was 4.1 0% stress defect in all territories.

tte showed ">55%ef, normal chamber sizes, wall motion." no mention of E/A ratio. of note, lv mass 108 grams, which is normal. (unless erroneously reported as grams and not g/m2) Also, LA size only 25 mm

An occult LEAK from the anastomosis causing massive inflammation, coupled with osteomalacia.

 

[pikachu]

With the pain, mildly elevated bilirubin/alk phos, and biliary tree/pancreatic duct dilation I would STRONGLY consider a pancreatic mass of some sort - focal chronic pancreatitis or a cancer - and get an endoscopic ultrasound and more dedicated pancreatic and biliary tree imaging (like an MRI/MRCP or pancreatic protocol thin slice CT). Perhaps a CA19-9 could also be useful.

 

[Hotsauce21]

Im not currently taking care of patient, but it seems chest>>abd pain right now. and abdominal pain is chronic.

 

[augmel]

I'm with Pili. Retroperitoneal bleed s/p second surgery. Diaphragmatic irritation causing chest pain.

 

[Hotsauce21]

OK, HERES PREVAILING OPINION

-hemolytic anemia. Etiology favors enzyme deficiency or membrane defect that was worsened by Tylenol(Vicodin) and Bactrim. (oxidizing agents)

She had no evidence of sickle or crystals on original smear. Also, heme mentions that is would be nearly impossible to not have crises before now if actaully had SS anemia.

Diffuse pain: believed secondary to osteomalacia and Vit D deficiency.

Recommendations:
-Continue to avoid foods and medications with oxidative potential
(including TYlenol, aspirin/bactrim)

-Vitd, calcium supplements.

*LE Edema and mild bilary/pancreatic ductal dilatation not evaluated more in depth. Keep in mind that its common for biliary duct to be dilated post chole. Not sure if definite cause for edema has been found outside of some hypoalbuminemia, chronic venous stasis.

 

[Pili]

OK, HERES PREVAILING OPINION

-hemolytic anemia. Etiology favors enzyme deficiency or membrane defect that was worsened by Tylenol(Vicodin) and Bactrim. (oxidizing agents)

She had no evidence of sickle or crystals on original smear. Also, heme mentions that is would be nearly impossible to not have crises before now if actaully had SS anemia.

Diffuse pain: believed secondary to osteomalacia and Vit D deficiency.

Recommendations:
-Continue to avoid foods and medications with oxidative potential
(including TYlenol, aspirin/bactrim)

-Vitd, calcium supplements.

*LE Edema and mild bilary/pancreatic ductal dilatation not evaluated more in depth. Keep in mind that its common for biliary duct to be dilated post chole

I continue to believe that an initial LEAK was present. Bariatric surgeons will tell you that those are possible even with negative post op EGD. Acid seeping from the stomach will cause bad diaphragmatic irritation, chest pain, some can be lethal with MOF. Subsequent splenomegaly might be responsible for the heme findings. It continues to amaze me that patients seek those surgeries unaware of the deadly complications.

 

[Hotsauce21]

Maybe so. An interesting case, nontheless, and you may be right there is missing pathology, somewhere. Difficult to say.

I continue to believe that an initial LEAK was present. Bariatric surgeons will tell you that those are possible even with negative post op EGD. Acid seeping from the stomach will cause bad diaphragmatic irritation, chest pain, some can be lethal with MOF. Subsequent splenomegaly might be responsible for the heme findings. It continues to amaze me that patients seek those surgeries unaware of the deadly complications.

 

[DoctorG]

I briefly browsed through the post (Guilty of ADHD). So forgive me if there's something I'm missing. Just a lonely med student.
I was just curious about the possibility of:
1. anemia sec to malabsorption (of say B12) s/p bypass.
2. chest/bone/abdominal pain sec to extramedullary hematopoesis.

 

[Hotsauce21]

1. no, b12 >1200
2. doubtfu, heme didnt say anything about it. is extramedullary hematopoiesis painful?