Interesting case if you want to play

[EM2BE]

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Disclaimer - no, we do not have a diagnosis yet, but have gotten a lot of negatives.

55 yo W female came into ED with CC of sore throat x5 days. Sinus surgery was done 1 month ago to remove a schwannoma. She was afebrile. Because her mucus membranes were dry, labs were run to see how dry she was. She received 3L NS in the ED, then was admitted to our service.

A few of the always asked labs:

Rapid strep - Neg

Chem- Gluc-120, Na-134, K-3.2, Cl-101, CO2-17, Anion gap-17, BUN-53, Cr-2.9, EGFR-18, Ca-8.8, CRP-36.3

CBC- WBC-11.5, RBC-4.92, HGB-15.3, HCT-43.6, PLT-125

U/A- spec grav->1.030, trace leuk est, prot-30, ketones-trace, bili-moderate, blood-small amt (0-2/HPF), WBC-5-10, moderate bacteria


Ask away and I'll give the answers if we have investigated that route.

EDIT: all labs are pre-treatment in the ED (not 3 days down the line and before fluids administered)

 

[drguy22]

blood smear showed?
Diff?
EBV titers?
TSH/T3/T4?
urea breath test?

 

[Old_Mil]

Disclaimer - no, we do not have a diagnosis yet, but have gotten a lot of negatives.

55 yo W female came into ED with CC of sore throat x5 days. Sinus surgery was done 1 month ago to remove a schwannoma. She was afebrile. Because her mucus membranes were dry, labs were run to see how dry she was. She received 3L NS in the ED, then was admitted to our service.

A few of the always asked labs:

Rapid strep - Neg

Chem- Gluc-120, Na-134, K-3.2, Cl-101, CO2-17, Anion gap-17, BUN-53, Cr-2.9, EGFR-18, Ca-8.8, CRP-36.3

CBC- WBC-11.5, RBC-4.92, HGB-15.3, HCT-43.6, PLT-125

U/A- spec grav->1.030, trace leuk est, prot-30, ketones-trace, bili-moderate, blood-small amt (0-2/HPF), WBC-5-10, moderate bacteria


Ask away and I'll give the answers if we have investigated that route.

in addition to what the previous poster said...

UA? Any casts?
Urine C&S?
Serum OSM?
Urine OSM?
Urine Cr?

RR, BP, P all normal?
PMH aside from Schwannoma?
PSH aside from Sinus surgery to address the same?
Social/Fam Hx?
Meds?

The ratio is pre-renal, but are her elevated BUN and Cr resolving with IV fluids?

 

[EM2BE]

blood smear showed?
Diff?
EBV titers?
TSH/T3/T4?
urea breath test?

Rest of CBC:
MCV-88.6, MCH-88.6, MCHC-35.1, RDW-13.4, MPV-8.7
Auto: lymph-1.1, mono-3.2, neut-95.0, eos-0.7, baso-0.0
ABS: lymph-0.1, mono-0.4, seg-10.9, eos-0.1, baso-0.0
Manual: Neut-65, bands-29, lymph-0, mono-3, eos-0, baso-0, metamyelocyte-2, RBC morph-normal, Dohle bodies-1, plt slide rv-decreased, atypical lymph-1

EBV-pending (will come Monday)
TSH/T3/T4-pending (will come Monday)
Urea breath test - not done

 

[EM2BE]

in addition to what the previous poster said...

UA? Any casts?
Urine C&S?
Serum OSM?
Urine OSM?
Urine Cr?

RR, BP, P all normal?
PMH aside from Schwannoma?
PSH aside from Sinus surgery to address the same?
Social/Fam Hx?
Meds?

The ratio is pre-renal, but are her elevated BUN and Cr resolving with IV fluids?

UA- calcium oxalate casts if I remember correctly - will let you know tomorrow if not
C&S: negative for growth
Serum and urine OSM, urine creatinine - not ordered

Initial VS: BP: 90/72, P-142, RR-18, Temp-98.5

HPI: Had sinus congestion and over last few days moved to throat.
PMH: nothing other than schwannoma
PSH: nothing other than surgery mentioned
Social: denies tobacco, drug abuse; drinks EtOH socially
PFH: As far as we know, nothing contributory

Post fluids chem includes BUN 25, Cr 0.7, EGFR>60

Meds: did include pepcid, after to the floor, this was d/c due to platelets. Otherwise nothing.

 

[drguy22]

any recent chemo?

what did physical exam show?

could she just have the common cold? flu? did she get a flu shot recently?

previous Cr? any NSAID use?

 

[EM2BE]

any recent chemo?
-No

what did physical exam show?
-consitutional: afebrile, nml RR, AAOx3, tachycardic, hypotensive
-ENT: post pharynx injected
-lymph: no adenopathy in neck
-everything normal if not stated

could she just have the common cold? flu? did she get a flu shot recently?
-no, no, and no

previous Cr? any NSAID use?
-no old records, no NSAID use

 

[drguy22]

CT head/sinus?

 

[EM2BE]

CT head/sinus?

Normal (possible muscle spasm in neck - did CT of neck too)

 

[Tiger26]

Diagnosis--Malingering😉

 

[had2piknowEM]

ANA, ANCAs...maybe some weird autoimmune disease. Has she ever been told that her kidneys weren't working properly?

 

[EM2BE]

Diagnosis--Malingering😉

At this point, I would like this diagnosis. However, for some reason, she can't fake the lab changes we've seen (or so we think she can't).

 

[EM2BE]

ANA, ANCAs...maybe some weird autoimmune disease. Has she ever been told that her kidneys weren't working properly?

Not run yet...may be in the works.

No history of kidney problems. However, as far as we can tell, her kidney function has restored since admission (with hydration).

Just to make you see part of one of the problems, day 4 platelets were 20 (x10 -3).

 

[drguy22]

Not run yet...may be in the works.

No history of kidney problems. However, as far as we can tell, her kidney function has restored since admission (with hydration).

Just to make you see part of one of the problems, day 4 platelets were 20 (x10 -3).

BM biopsy? id also like a list or meds. pls🙂

 

[SoCuteMD]

What do you mean by x10 -3?

 

[EM2BE]

What do you mean by x10 -3?

that's the normal lab labeling (was just saying it so that someone didn't think there were 20 in any other direction)

 

[EM2BE]

BM biopsy? id also like a list or meds. pls🙂

No biopsy. On TPN w/ ensure as tolerated (throat pain).

Here's the specific list (as of day 3):
Pantoprazole (Protonix)
Lorazepam (Ativan)
Cipro
Hydromorphone
Amp/sulbactam (Unasyn)
Famotidine (Pepcid)
Morphine

 

[SoCuteMD]

Uh, didn't you mean x10^3?

 

[EM2BE]

Uh, didn't you mean x10^3?

Ya...forgot the carrot function. Hard to type superscript on here 😉

 

[Schnoffle]

Do we know if there were any complications during the surgery?
Also:
Any history of rhinorrhea with the nasal congestion?
Any productive cough/hemoptysis?
Have you noticed any increased bruising/bleeding since the platelet drop? Petechiae formation?
Splenomegaly signs?
I guess a work up for ITP and TTP is in there as well

Also, when you say her kidney function has returned with hydration, do you mean the Cr level as dropped at all? Guess HUS can always be a possiblily, but would expect it to be a lot worse for her if that was the case 😉

 

[drguy22]

No biopsy. On TPN w/ ensure as tolerated (throat pain).

Here's the specific list (as of day 3):
Pantoprazole (Protonix)
Lorazepam (Ativan)
Cipro
Hydromorphone
Amp/sulbactam (Unasyn)
Famotidine (Pepcid)
Morphine

low platelet count and shes on famotidin/PPI? also unasyn can cause low PLTS 2.... why is she on the abx?

 

[EM2BE]

Do we know if there were any complications during the surgery? None noted.
Also:
Any history of rhinorrhea with the nasal congestion? No
Any productive cough/hemoptysis? No
Have you noticed any increased bruising/bleeding since the platelet drop? No Petechiae formation? Yes - LE
Splenomegaly signs? No
I guess a work up for ITP and TTP is in there as well - working on it

Also, when you say her kidney function has returned with hydration, do you mean the Cr level as dropped at all? Serum Cr was 1.1 day 2, 0.7 day 3

Guess HUS can always be a possiblily, but would expect it to be a lot worse for her if that was the case 😉 We were thinking the same thing

 

[EM2BE]

low platelet count and shes on famotidin/PPI? also unasyn can cause low PLTS 2.... why is she on the abx?

They looked into this (famotidine) and discontinued it on day 2 or 3.

On abx - was started in ED, d/c on floor, restarted on different abx on the floor after change in mental status on day 4 (for treatment of possible meningitis/encephalitis).

 

[drguy22]

Pt/ptt/inr?

 

[Schnoffle]

What was the change in mental status? makes you wonder if she is forming extra clots and some got sent to the brain

 

[EM2BE]

Pt/ptt/inr?

Day 2
PT-14.7
INR-1.2
PTT-35.4

Forgot -concerning an above question -PE did show axillary node inflammation on day 2 or 3 to present.

 

[EM2BE]

What was the change in mental status? makes you wonder if she is forming extra clots and some got sent to the brain

She thought she was in a trailer home. No sense of time either. Barely arousable - only to touch, not voices.

Head CT was ordered before leaving on Fri - haven't been back to see the results yet (hopefully I will be able to come tomorrow - heard rumor she may be going to the ICU)

 

[Schnoffle]

can't remember if this was asked, but any chance of a D-dimer being checked? Just wondering if there is any other evidence of rapid clot formation/breakdown

 

[EM2BE]

can't remember if this was asked, but any chance of a D-dimer being checked? Just wondering if there is any other evidence of rapid clot formation/breakdown

Not asked yet- D-dimer was 8.24 on day 2.

 

[Schnoffle]

guess i should have asked this with the d-dimer question:
Any U/S duplex of UE/LE or possibly carotid?

 

[drguy22]

my diff:

ITP
Drug induced thrombocytopenia

 

[SoCuteMD]

Does the patient have any neuro symptoms?

 

[deleted65604]

lemierre's syndrome (what are results of blood culture and CT neck?)

 

[roja]

did she recieve post surgical anticoagulation? (heparin, lovenox)

HIT is possible...

 

[RxnMan]

I was thinking Wegener's/MPA too until I saw that her renal function improved with hydration.

...Guess HUS can always be a possiblily, but would expect it to be a lot worse for her if that was the case 😉 We were thinking the same thing

Does she have mental status changes?

 

[RxnMan]

Day 2
PT-14.7
INR-1.2
PTT-35.4

Forgot -concerning an above question -PE did show axillary node inflammation on day 2 or 3 to present.

She thought she was in a trailer home. No sense of time either. Barely arousable - only to touch, not voices.

Head CT was ordered before leaving on Fri - haven't been back to see the results yet (hopefully I will be able to come tomorrow - heard rumor she may be going to the ICU)

D'oh. Read the rest of the thread. With thrombocytopenia, mental status changes, acute renal dysfunction, and anemia, it points to HUS.

Did she have a fever?

Did you get a haptoglobin or a fractionated bili?

 

[hyperbaric]

lemierre's syndrome (what are results of blood culture and CT neck?)

Fusobacterium? nice differential!

 

[shortbread9]

Anyone that has had surgery to their face/neck/sinuses that has mental status change you should consider venous sinus thrombosis (dehydration can also be a precipitating cause).
Look on head ct for the "empty delta" sign.

 

[EM2BE]

I guess I started this thread too early. Pt ended up getting transferred to another hospital over the weekend. Haven't heard anything about it since, but will keep searching (for a final answer). I am enjoying hearing some of the differentials you all are coming up with. Some we came up with, others not. Here is the info we had at transfer:

First of all, yes, there was a mental status change. Unresponsive at times. No definitive cause - sent to MICU when didn't resolve over 5-6 hours.

To answer another question, she did take Aleve chronically, but what that means (i.e. once a month or 5x / day) I'm not sure.

Day 3 blood gases:
pH - 7.43
pCO2 - 33
pO2 - 65
HCO3 - 22
BE - -1.9
O2 sat calc - 93.0
O2 sat meas - 95.7
FIO2% - 21.0

Day 4 Chem:
Gluc - 156
Na - 137
K - 3.4
Cl - 107
CO2 - 25
Anion Gap - 8.4
BUN - 18
Cr - 0.5
EGFR - >60
Ca - 8.4
P - 2.1
Mg - 1.9
Bili T - 3.6
Bili Direct - 2.2
Bili indirect - 1.4
Protein - 4.1
Albumin - 2.5
Alk Phos - 150
ALT - 65
AST - 35
LDH - 220
Ammonia - 73.0
Lactate - 1.4
CRP - 8.4
Haptoglobin - 246

Day 4 Cardiac enzymes
BNP - 318

Day 4 Endo
HbA1C - 5.6
TSH - 2.303

Day 2 UDS
+ Opiates (possibly due to meds given prior to test - pt denies use)

Hematology Day 4
WBC - 14.7
RBC - 2.99
HGB - 9.2
HCT - 26.6
MCV - 88.9
MCH - 30.6
MCHC - 34.5
RDW - 14.5
MPV - 8.6
PLT - 22
Manual Diff (day 2):
Neut - 65
Bands % - 29
Lymph - 0
Mono - 3
Eos - 0
Baso - 0
Metamyelocyte - 2
RBC morph - Normal
Dohle bodies - 1+
Plt slide rv - decreased
Atypical lymph - 1

ID days 1-4
HepB neg
Lyme neg
Strep neg
HIV neg

Coags Day 3
PT - 14.7
INR - 1.2
PTT - 35.4
Fibrinogen - 399
D Dimer - 8.24

U/A Day 4
Normal except Moderate amt of bili
Old U/A (day 1) - cloudy, Sp Grav - >1.030, trace leuk est, 30 nitrites, trace ketones, moderate amt bili, small amt blood (0-2 RBCs), 5-10 WBCs, Moderate bacteria, 0-1 casts - course granular

Cultures Day 4 (results returned day 4)
Blood and urine - no growth
Sinus - staph

Radiology
Day 2 - V/Q scan: low probability
Day 2 - CXR: questionable large R effusion
Day 2 - Angio chest CT - elevated R hemidiaphragm, possible atelectasis
Day 3 - Head CT s contrast - R maxillary sinusitis
Day 4 - RUQ/LUQ US - gallbladder wall thickened

Cardio
2D echo: mild tricuspid regurg, mild increase in pulm artery sysolic pressure, mild mitral regurg
EKG: Sinus tach, nonspecific ST and T wave changes, possible age indeterminate inferior wall infarct

Consults - their differentials:
CSF leak secondary to surgery
Meningitis (because of petechial rash on b/l LE)
Zygomycosis - (if) black/brown eschar in sinus cavity
Thrombocytopenia or systemic infection (b/c worsening plt levels)

Meds suggested by consults:
ceftriaxone
vancomycin
ampho B
rocephin



This is all I have for now. I may be able to help with minor questions about the case, but other than the data listed, there is nothing more recent.

 

[kungfufishing]

Has a lot of TTP findings (?)

 

[EM2BE]

Has a lot of TTP findings (?)

We had a discussion about this (and the other thrombocytopenias). She also had no purpura (just had the petechiae) Since the ARF seemed to disappear with fluids, we were leaning less toward this diagnosis.

In the end of our seeing her, she had mental status change, throat so sore that she couldn't eat or swallow, thrombocytopenia, petechiae which appeared better on day 4 than day 3, and was never febrile.

We also considered the heparin post op, but that was 4-5 wks post op when she presented and the timeline didn't quite fit for HIT.

The part of no fever complicated most theories we came up with. The other factor that we couldn't get to work was the ARF (because of the resolution with IV fluids). And then there's the extremely sore throat. We think there was a part of the story missing because we couldn't find a diagnosis to really fit her symptoms and lab values. For instance, her labs looked terrible on days 1-3, yet she appeared well and was in no pain other than the throat.

Needless to say, all of us that saw her are still puzzled as to what it could have been. I'm guessing she had more than one process, and one was complicated by the other.

 

[Apollyon]

Just talked about TTP over the weekend with one of those crusty old IM attendings that knows EVERYTHING and EVERYONE, and still slogs it out. In summary, he said that people will think it's ITP, give them steroids, and wait, and, when they finally call heme/onc, and H/O says it's TTP, when the plasmapheresis starts, it's too late.

HUS/ITP - you'll live. TTP - you won't. Hope Heme/Onc is on board.

 

[EM2BE]

Just talked about TTP over the weekend with one of those crusty old IM attendings that knows EVERYTHING and EVERYONE, and still slogs it out. In summary, he said that people will think it's ITP, give them steroids, and wait, and, when they finally call heme/onc, and H/O says it's TTP, when the plasmapheresis starts, it's too late.

HUS/ITP - you'll live. TTP - you won't. Hope Heme/Onc is on board.

They were consulted prior to transfer. Due to record retrieving complications, I didn't have a report from them (or they didn't make it before the transport). Will continue to look throughout the week to see if there is anything else posted on the computerized chart. Good to know about the fuzziness of TTP. I always wondered how a person could know.

 

[SoCuteMD]

Has a lot of TTP findings (?)

That's why I asked about neuro exam.

I had an EM attending (roja - you know this lovely lady!) who often put TTP in the differential. After some reading on it, I do too know.

And hey, even if you are wrong, at least you sound smart!

 

[dchristismi]

It did sound more like TTP, and you certainly don't have to have the whole pentad. Tought case.

It's hard to get follow up on transfers. I'm still trying to follow up on a dude I shipped a couple of weeks ago (ended up cricing him,so I'm dying to know what the hell happened.)

 

[Schnoffle]

I think it is interesting that on the Day 4 labs her Ammonia had jumped up it seems a bit. Any indication that this could have caused some of the mental status change instead?

Clots makes more sense to me considering the platelet drop, but wasn't sure if this added to it at all. I guess that is what makes me the med student 😉 Any chance the increasing sore throat could be due to a minor ischemic event to the muscles in the area? That's out there, I know, but just trying to figure it out. If she's still NPO, maybe her throat is just getting dryer 😉

 

[vtucci]

Waiting for someone to throw out lupus on the differential. Thrombocytopenia, AMS, ?effusion on CXR, anemia, acute renal involvement, abnl cardiac findings


If we were on House, it would come up as sero-negative lupus.

Did you guys run the ANA, ANCAs, anti-smith, lupus anticoag? I have not seen an answer to this earlier question. Any more recent coags?

 

[EM2BE]

Waiting for someone to throw out lupus on the differential. Thrombocytopenia, AMS, ?effusion on CXR, anemia, acute renal involvement, abnl cardiac findings


If we were on House, it would come up as sero-negative lupus.

Did you guys run the ANA, ANCAs, anti-smith, lupus anticoag? I have not seen an answer to this earlier question. Any more recent coags?

I posted all labs that I had available. I think a few of the above were ordered, but do not know what was done prior to transfer.

Funny you mention House - the patient and her sig other asked why we just don't start treatment for what we think it is like they do on House.

 

[vtucci]

That was why I mentioned House.

When I did my away rotation earlier this year, one of my patients wanted to know if our sex lives are really like Grey's Anatomy. Entirely too much silliness on some of these shows.

 

[EM2BE]

That was why I mentioned House.

When I did my away rotation earlier this year, one of my patients wanted to know if our sex lives are really like Grey's Anatomy. Entirely too much silliness on some of these shows.

I've heard some parents ask their med school kids this.