Interesting Cases that we've had:

[DrQuinn]

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Hey guys... I'm pretty bored here and am preparing for another long call night tomorrow (Tuesday) in the MICU, so I figured we would try something that some other forums have done... (especially IM, those mental masturbators), a "case study" thread, where we can post interesting cases that hopefully we all can learn from! I'll start.

51 year old woman with history of asthma/allergic rhinitis presents to ED with two weeks of neck and left arm pain, worse with movement, described as "achy." Started when she had a tooth cap placed two weeks before. The day after her dental procedure, the patient noticed significant swelling and tenderness. She went to her PCP who prescribed her with what she believes is "Avelox." She took the Avelox and broke out in a rash on her face and chest. Went to see her "Allergist" who prescribed a Medrol Dose Pak and told her she was either allergic to novocaine or "Avelox." Rash went away.

Of note, patient has been having intermittent "rashes" and "urticaria" for the past two years, treated with Vistal and Medrol Dose Paks.

Presents to ED, EKG showed NSST/TW Changes. Troponin is 4.0. CBC shows a WBC count of 20, with 50% eosinophilia. Rest of labwork unremarkable. Vital signs unremarkable. Physical exam shows reproducible left arm and neck tenderness. No swelling, no tenderness anywhere. No other pertinetn PE findings.

Admitted to small dinky hospital. Cath negative. EF normal. Echo normal. Troponins continue to rise for 5 days during her hospital stay. Patient deteriorates on day 5, transferred to tertiary care center. Troponins 25, patient now A+O x 1.


Dx with Churg-Strauss Syndrome. Given high dose steroids, IVIG. Patient intubated, started on pressors (continues to deteriorate), intra-aortic balloon pump, more pressors. Expires within 24 hours of transfer to tertiary care center.

P-ANCA negative. RF negative. ANA negative. Eosinophils were constantly 40+%. Troponin was 120 her last day. Echo shows severe MR, moderate TR, hyperdynamic, EF ~ 50%. CXR no infiltrates, moderately enlarged cardiac silouette.

Autopsy pending.

Learning point: Chest pain, positive troponins, eosinophilia, history of allergic rhinitis/asthma, 2 year history of intermittent hives/rash:
DDX: Churg Strauss (asthma, eosinophilia, and vasculitis) vs eosinophilia syndrome.

On her last day, patient's Cr began to rise, LFT's rose, troponins continuedt o elevate, and her head CT showed evidence of vasculitis. No skin lesions. She had 4 out of 5 poor prognostic indicators for Churg-Strauss Syndrome.

Q, DO

 

[Kalel]

You do realize that in IM, we don't give away the answer to our case presentations right away with a final diagnosis without a long differential and discussion. 😉 This is funny, I PMed Andrew a while ago about how his cases were presented and discussed like surgical cases with short differentials and without the long-winded responses and explanations we do in IM, while your EM case appears to cut to the chase with the answer before we even really get into the case.

 

[Seaglass]

That's how we like it. Short and sweet.

C

 

[spyderdoc]

50 yo AAF with Hx DM, Renal transplant (3-4 yrs ago) after years of HD (no HD since transplant). There is a Hx of HTN, and a recent echo shows a LVEF of 60% with no abnormalities...Pt c/o increasing DOE, orthopnea. No CP, cough, F/C/S. On exam, Pt is in moderate respiratory distress, has slight JVD, bilateral rales, no murmurs, no peripheral edema. She has old AV fistulas to bilateral arms, one of which has a thrill. CXR shows mild CHF. Labs show the transplanted renal function is great, normal troponin, nl wbc. The patient responds to lasix, but is still dyspneic....
Pt admitted to medicine and worked up for the etiology of the CHF...Any guesses?

 

[docB]

50 yo AAF with Hx DM, Renal transplant (3-4 yrs ago) after years of HD (no HD since transplant). There is a Hx of HTN, and a recent echo shows a LVEF of 60% with no abnormalities...Pt c/o increasing DOE, orthopnea. No CP, cough, F/C/S. On exam, Pt is in moderate respiratory distress, has slight JVD, bilateral rales, no murmurs, no peripheral edema. She has old AV fistulas to bilateral arms, one of which has a thrill. CXR shows mild CHF. Labs show the transplanted renal function is great, normal troponin, nl wbc. The patient responds to lasix, but is still dyspneic....
Pt admitted to medicine and worked up for the etiology of the CHF...Any guesses?

Cor pulmonale? High output failure due to the fistulas?

 

[Kalel]

Could be diastolic dysfunction secondary to something like LVH too. I'd also consider new-onset systolic dysfunction secondary to a large number of predisposing factors that a post-kidney transplant patient has (eg CAD, htn, chronic anemia, immunosuppressive toxicities, etc). A PE w/u is almost always appropriate in dyspnic patients too.

 

[spyderdoc]

High output failure due to the fistulas?

Excellent! She was admitted for CHF. She got the million dollar workup, and they found the CHF to be high output from the fistulas....very interesting to me....just something else to consider in these pts....

 

[DrQuinn]

Excellent! She was admitted for CHF. She got the million dollar workup, and they found the CHF to be high output from the fistulas....very interesting to me....just something else to consider in these pts....

Interesting! Thanks!

Q, DO

 

[DrQuinn]

You do realize that in IM, we don't give away the answer to our case presentations right away with a final diagnosis without a long differential and discussion. 😉 This is funny, I PMed Andrew a while ago about how his cases were presented and discussed like surgical cases with short differentials and without the long-winded responses and explanations we do in IM, while your EM case appears to cut to the chase with the answer before we even really get into the case.

'Tis the difference between IM and EM. My attnetion span won't allow for such long winded discussions. And I could care less about the transtubular potassium gradient, or the specificity of the urinary Legionella antigen. Just pullin' IM's chain. See Spyderdoc's case above, nice, short, and sweet.

Q, DO

 

[Red Beard]

BUMP.

Was gonna post an 'interesting cases' thread but saw this one in the search.

So whatcha got?

 

[po' boy]

in the past four days:
-two STEMIS, including one in a 35 year old who ended up having multivessel disease on cath and went for CABG yesterday
-an acute CVA
-a nec fasc of the leg, went for emergent AKA, now on dialysis and had an NSTEMI
-hypertensive emergency with altered MS, intubated and went for emergent dialysis
-a bowel obstruction that caused strangulated/dead bowel from a Meckel's diverticulum, went to OR emergently and made the diagnosis there
-back pain from newly diagnosed masses to L spine with cauda equina syndrome, probable lung CA primary vs. lymphoma
and others. Lots of sick patients this weekend, glad to have tomorrow off. When i left tonight there were 27 patients in the waiting room of my 9 bed ER, since the other ERS in my area had been on diversion all day.

 

[DeLaughterDO]

in the past four days:
-two STEMIS, including one in a 35 year old who ended up having multivessel disease on cath and went for CABG yesterday
-an acute CVA
-a nec fasc of the leg, went for emergent AKA, now on dialysis and had an NSTEMI
-hypertensive emergency with altered MS, intubated and went for emergent dialysis
-a bowel obstruction that caused strangulated/dead bowel from a Meckel's diverticulum, went to OR emergently and made the diagnosis there
-back pain from newly diagnosed masses to L spine with cauda equina syndrome, probable lung CA primary vs. lymphoma
and others. Lots of sick patients this weekend, glad to have tomorrow off. When i left tonight there were 27 patients in the waiting room of my 9 bed ER, since the other ERS in my area had been on diversion all day.

Sounds like it might be time for your ED to go on divert as well.

One I saw tonight:

17 y/o male presents to the ED with orthostatic lightheadedness x 4 days. No rotation. No syncope. Had diarrheal illness until 2 days ago, nonbloody. Not watery, just softer and more frequent than usual (5-7 stools a day). Some mild lower abdominal crampy pain associated with the diarrhea, no pain now. Drinking fine, decreased appetite.

ROS: no fevers, occ chills, occ sweats, no headache, no visual changes, no neck pain/stiffness, no shortness of breath, no palpitations, no chest pain/pressure, no back pain, no rash, no bruising, no lumps.

Otherwise healthy and takes no meds.
SocHx - + smoker, denies EtOH or other drugs

Vitals: afebrile, tachy in 100s, SBP about 120mmHg

On exam, is pale, but otherwise nontoxic appearing.
Conj pale, nonicteric
No adenopathy
lungs clear
tachycardic about 107 at rest
Abdomen flat, soft, normal bowel sounds, nontender, no organomegaly
no rash/bruising
No edema, strengths normal, pulses normal

Doesn't look too bad, but when you stand him up to check orthostatics he sways and has to sit back down. Otherwise, completely nontoxic.

CBC/diff: WBC 38K with 25% blasts, 9%metas, 9% myelos, 9% bands, 14% segs. Hgb 4.8 and platelets 58k
BMP with normal renal function, no acidosis, no AG

thought HOLY CRAP and sent second round of labs, including LFTs, iron studies, LDH, uric acid, retic, peripheral smear, Fibrin split products, coags.

LFTs normal, coags normal, fibrin splits negative - doesn't appear to be hemolysis (HUS/TTP)
LDH elevated, uric acid not elevated (kind of unexpected)
Retic count not elevated
Ferritin elevated, TIBC decreased

Transfused, admitted.
Peripheral smear pending (will be done during normal pathology hours in AM)

17 year old kid probably has leukemia. Will have bone marrow later for confirmation. I just love having those conversations with people.

Diagnosed a guy with brain cancer the other day too, only symptom he had was LUE tremor and feeling like he wanted to fall to the left... Don't know why I hate telling people they probably have cancer more than anything else. Something to do with the stigma of the big Casino, I guess.

 

[DeLaughterDO]

BTW, congrats on resurrecting a 5 year old thread. One of the most impressive I've seen in quite a while. 🙂

 

[gutonc]

Sounds like it might be time for your ED to go on divert as well.

One I saw tonight:

17 y/o male presents to the ED with orthostatic lightheadedness x 4 days. No rotation. No syncope. Had diarrheal illness until 2 days ago, nonbloody. Not watery, just softer and more frequent than usual (5-7 stools a day). Some mild lower abdominal crampy pain associated with the diarrhea, no pain now. Drinking fine, decreased appetite.

So, this may be b/c I'm an onc fellow but by the time I finished reading this sentence, I thought "I wonder what kind of leukemia this kid has?". I do not envy you having to have this discussion in the ED. It's hard enough when they already kind of know what's up.

 

[Termwean]

What was it about this HPI that made you think leukemia?

So, this may be b/c I'm an onc fellow but by the time I finished reading this sentence, I thought "I wonder what kind of leukemia this kid has?". I do not envy you having to have this discussion in the ED. It's hard enough when they already kind of know what's up.

 

[Red Beard]

What was it about this HPI that made you think leukemia?

I'm guessing the high white count, anemia without evidence of bleed, and constitutional symptoms in an afebrile kid? I'd be curious just how elevated the LDH was, and if the retic count was normal or if it was low...

 

[Termwean]

Oh, I misunderstood. I thought he said that he asked himself that question while reading this:

"17 y/o male presents to the ED with orthostatic lightheadedness x 4 days. No rotation. No syncope. Had diarrheal illness until 2 days ago, nonbloody. Not watery, just softer and more frequent than usual (5-7 stools a day). Some mild lower abdominal crampy pain associated with the diarrhea, no pain now. Drinking fine, decreased appetite."

I understand when looking at the complete HPI/exam/labs

Thanks

I'm guessing the high white count, anemia without evidence of bleed, and constitutional symptoms in an afebrile kid? I'd be curious just how elevated the LDH was, and if the retic count was normal or if it was low...

 

[DeLaughterDO]

I'm guessing the high white count, anemia without evidence of bleed, and constitutional symptoms in an afebrile kid? I'd be curious just how elevated the LDH was, and if the retic count was normal or if it was low...

LDH was in 500s, uric acid was in normal range. Retic count was definitely not appropriately elevated given how anemic this kid was. IIRC the retics were about 1.7% of total RBCs... pretty depressed, if you ask me.

 

[DeLaughterDO]

So, this may be b/c I'm an onc fellow but by the time I finished reading this sentence, I thought "I wonder what kind of leukemia this kid has?". I do not envy you having to have this discussion in the ED. It's hard enough when they already kind of know what's up.

I couched it in (what is becoming) my usual fashion for people who I think have cancer: we found some abnormalities on (insert test here). We're not exactly sure what it means yet, and will need to run some more tests to find out... I try to encourage them to not freak until we have all the answers, because at this early stage, I may be way off.

I then discuss some of the possibilities briefly and answer what questions I can, leaving those I am not sure of (what kinds of tests, etc) to the consulting team. I also let the consultants know what I have discussed with the patient/family.

Maybe this is wrong, but in most cases, I think it is better for the family to know why their loved one is having to have more blood drawn, go for CT/MRI, and having a bone marrow planned the next day... I would want to know what is going on.

What are your thoughts?

 

[BADMD]

55 year old schizophrenic guy presents to the ED with weakness that is gradually worsening over a few weeks. Hgb 4.6, WBC 1.1, ANC 200. No source of bleeding. No abnormal cells on peripheral smear. Otherwise feels fine. ANC drifts down to 0.

Abd xray show hundreds of metallic foreign bodies....pennies. He had Zn toxicity with resulting Cu deficiency. Lots of Golytely to get the pennies out and a lot of IV copper and he was fixed.

 

[gutonc]

I couched it in (what is becoming) my usual fashion for people who I think have cancer: we found some abnormalities on (insert test here). We're not exactly sure what it means yet, and will need to run some more tests to find out... I try to encourage them to not freak until we have all the answers, because at this early stage, I may be way off.

I then discuss some of the possibilities briefly and answer what questions I can, leaving those I am not sure of (what kinds of tests, etc) to the consulting team. I also let the consultants know what I have discussed with the patient/family.

Maybe this is wrong, but in most cases, I think it is better for the family to know why their loved one is having to have more blood drawn, go for CT/MRI, and having a bone marrow planned the next day... I would want to know what is going on.

What are your thoughts?

I think you handle it pretty well. The thing I find frustrating is when somebody (an EP, a PCP, a surgeon, whomever) sees a lesion on imaging or a lab value and tells the patient "you have X cancer, you need to seen an oncologist." I like your approach. Makes my life easier down the road.

 

[WilcoWorld]

I realize he's been banned, so really no need to beat a dead horse, but "A PE w/u is almost always appropriate in dyspnic patient." Sheesh!

 

[WilcoWorld]

22 yo f presents to ED with epigastric abdominal pain + N/V. Noted to be jaundiced on exam & LFT's reveal acute hepatitis. No chole. Coags OK, so she's d/c'd on metaclopramide (Reglan) with outpt GI f/u.

3 days later comes back with persistent nausea & now has bilateral breast discharge. No breast abscess or focal tenderness. Labs essentially unchanged.

what's up?

 

[gutonc]

What was it about this HPI that made you think leukemia?

I'm an oncologist...it's just my bias. 17yo w/ orthostasis/fatigue and other vague sxs sounds anemic to me. Why would a 17yo be anemic? Leukemia. I've also written this H+P enough times...it's pattern recognition.

 

[goofE1]

"22 yo f presents to ED with epigastric abdominal pain + N/V. Noted to be jaundiced on exam & LFT's reveal acute hepatitis. No chole. Coags OK, so she's d/c'd on metaclopramide (Reglan) with outpt GI f/u.

3 days later comes back with persistent nausea & now has bilateral breast discharge. No breast abscess or focal tenderness. Labs essentially unchanged.

what's up?"


OOH, OOH, I know this one! Dopamine antagonist (Reglan)= increased prolactin production = bilateral breast discharge. Still nauseous b/c hepatitis nasty stuff.

Been a bad day. Needed to feel like not an idiot. 🙄

 

[WilcoWorld]

OOH, OOH, I know this one! Dopamine antagonist (Reglan)= increased prolactin production = bilateral breast discharge. Still nauseous b/c hepatitis nasty stuff.

Been a bad day. Needed to feel like not an idiot. 🙄

Nice!

Aside from the semantic point that "increased prolactin production" should be termed "disinhibited prolactin release" you got it totally (and quickly) correct. And yeah, the persistent nausea was just a clue that she was still taking the Reglan 'round the clock.

 

[dmitrinyr]

I couched it in (what is becoming) my usual fashion for people who I think have cancer: we found some abnormalities on (insert test here). We're not exactly sure what it means yet, and will need to run some more tests to find out... I try to encourage them to not freak until we have all the answers, because at this early stage, I may be way off.

I then discuss some of the possibilities briefly and answer what questions I can, leaving those I am not sure of (what kinds of tests, etc) to the consulting team. I also let the consultants know what I have discussed with the patient/family.

Maybe this is wrong, but in most cases, I think it is better for the family to know why their loved one is having to have more blood drawn, go for CT/MRI, and having a bone marrow planned the next day... I would want to know what is going on.


What are your thoughts?

This is the better way to deal with this situation. I've had to deal with this situation a few times and I think that it's best to leave the word CANCER and the possibility until the nearing the END of your discussion of the differential Dx of pt's symptoms, even if there's a high chance that the pt has CA.

I think it's best to tell them that" With this type of presentation and this type of radiologic/blood work findings, I think you can be suffering from (enter possible explanation/etiology that's less severe and probably less chance of being true).... there is also a possibility that the findings are due to a growth/abnormal production of (enter organ/cell/etc.) and we will need to do extra tests/xrays/etc. and have specialists come talk to you in order for us to determine what is causing your symptoms.

The fact is that, once people hear the word CANCER, they will almost always basically stop listening to the rest of the explanation or discussion (much like hearing the word DEATH) and so if you come in and the first thing you say is "you might have cancer", the pt will be shocked and not hear anything else. Much like DeLaughterDO, I think it's best to ease the pt into the discussion of etiology and then mention cancer, even if you know that the pt almost certaintly has CA. Still a situation I hate, we all do.

 

[J-Rad]

In my peds residency I was on PICU call. Six months apart the same patient was admitted to my PICU (on the night I was on) for different things (one far more routine than the other). The first time the patient was 13 or so-is months old, previously healthy. The call from the ED was " we have this pt. with a K of 7.8, EKG changes, and it looks like the K+ is real. We're doing our hyperkalemia protocol." She got albuterol as part of the Tx for her K+, but they had also noted that she was breathing funny. She definitley was, but was not wheezing and was moving air fantastically. The ED did a great workup and we had the diagnosis just about the time we were getting her upstairs. Wanna work it though? Just to eliminate some easy ones, it was not ingestion and it was not cancer (no tumor lysis). If not I can just tell what it was.

 

[LadyGrey]

Were there other lab abnormalities? (Na+? Glucose?) I'm wondering about Addison's, but maybe I'm way off...

 

[SoCuteMD]

Breathing funny - Kussmauls resps? Acidosis - DKA, congenital metab defect (a bit late, though)

 

[J-Rad]

I'm not at the same facility anymore, so I'm going from memory, but the Na+ and glucose were WNL. What other labs did you want? Negative ketones. Anything else SoCute, (you have an interesting thought)?

PS These scenarios always risk getting too close to "guess what I'm thinking" so if I err too far that way, let me know.

 

[J-Rad]

Oh, I'll add:
CC-Breathing funny, not acting well
HPI-Previously healthy. Developed odd breathing pattern late in day and looked like she didn't feel well. Was awake or arousable, but not acting quite right. Far less active during the day.
PMH/PSH-Non contributory birth Hx. No other medical problems. Up to date on imms and no developmental issues noted in the past.
FamHx-Fa-DMII. O/W non-contributory.
No meds or allergies.

 

[SoCuteMD]

Oh, I'll add:
CC-Breathing funny, not acting well
HPI-Previously healthy. Developed odd breathing pattern late in day and looked like she didn't feel well. Was awake or arousable, but not acting quite right. Far less active during the day.
PMH/PSH-Non contributory birth Hx. No other medical problems. Up to date on imms and no developmental issues noted in the past.
FamHx-Fa-DMII. O/W non-contributory.
No meds or allergies.

Hmmmm...so maybe Kussmaul's resps. I'm not very familiar with most of the childhood metabolic defects, but most present before 6 months of age - correct? What's her BUN/Creatinine? Could we have renal failure (although I'm not sure what could precipitate such sudden RF other than ingestion, which you said it wasn't).

 

[J-Rad]

Hmmmm...so maybe Kussmaul's resps. I'm not very familiar with most of the childhood metabolic defects, but most present before 6 months of age - correct? What's her BUN/Creatinine? Could we have renal failure (although I'm not sure what could precipitate such sudden RF other than ingestion, which you said it wasn't).

http://emedicine.medscape.com/article/804757-overview
A late presentation of an IEM appropriately belongs on your DDx, but this is going to be one of your zebras. Her actual dx falls under the not common but not rare category. But you keep saying something and aren't asking for the data to support it...and it's easily available.
Speaking against late presenting IEM is the normal growth and development. Lets also say she had a normal ammonia , which I think she did (but where I trained I wasn't going to find that out for at least 5 hours after the labs were sent).
RFTs were basically normal.

 

[leviathan]

An ABG would be nice.

 

[EM2BE]

An ABG would be nice.

Also radiological results.

 

[J-Rad]

An ABG would be nice.

Also radiological results.

CXR normal. ABG 7.5/30/100.

 

[EastCoaster78]

CXR normal. ABG 7.5/30/100.

Physical exam? Echo?

 

[J-Rad]

Physical exam? Echo?

PE: Non dysmorphic. Awake, but clearly not feeling well. Pupillary exam normal. Other HEENT negative. Lungs clear and moving air well. In fact, taking deep breaths with this odd resp. pattern. Heart-slightly tachy, no M/R/G/T. Pulses OK. Abd-No organomegaly, benign abd. Extrem-no cyanosis, edema, abn of digits. Not moving limbs a whole lot (though this was actually something noted more prominently later)

Echo? No cardiomegaly and normal CV physical exam. EKG c/w changes seen with hyperkalemia. O/W NSR. Why echo? Besides the peds cardiologist won't be in for another 30 minutes if you want him.

(For the MSs, in the ED and in critical care units you usually don't get all your ancillary data piecemeal. You're going to send off a battery of tests that you can get reasonable quickly and then add on as needed. With a gas there is at least one other crucial lab. I personally still like the idea of Kussmal respirations)

 

[lucky_deadman]

CXR normal. ABG 7.5/30/100.

You said no ingestion. But I still gotta think Salicylates.

Have the parents been giving ASA, using any rubs/creams on child?

 

[J-Rad]

No h/o above. Salic. and APAP levels zero at zero and four hour mark. Still also have to think APAP OD as well.