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October 29, 2007
Presenter: Dr. Chandra Duggirala
“69-year-old female who presents with a one month history of fever, weakness, and cough…”
Today’s case centered on a 69-year-old female with a past medical history of hypertension, ESRD secondary to HTN and s/p two cadaveric renal transplants, who presented to the ED with the complaint of fever, weakness, and cough.  The patient stated that her symptoms began one month prior to admission, when she noticed a small nodule on her left forearm.  The nodule started off as a small one centimeter lesion that progressed to two centimeters after four weeks.  Two weeks after she noticed her nodule, the patient described fevers, fatigue, and a non-productive cough associated with exertional dyspnea.  The patient denied chest pain, palpitations, orthopnea, or PND.  The patient did admit to a 6 pound weight loss (over a period of one month) and hoarseness.  The patient had a 35 pack year smoking history, but denied the use of alcohol or illicit drugs.  Her family history was significant for maternal breast cancer, and paternal coronary artery disease.  Her medications included Prednisone, Cyclosporine, mycophenolate mofetil, Protonix, simvastatin, and amlodipine.

The Physical Exam revealed:
VITALS: T=99.8; P=107; BP=110/60; R=24
GEN: Appeared chronically ill
HEENT: Mild pallor, unremarkable oral mucosa
NECK: No LA, no thyromegaly, no JVD
CV: Tachycardic, regular rhythm, no murmurs
LUNGS: Inspiratory crackles in the right base and decreased breath sounds at the left base.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXT: No edema, normal pulses in all four extremities.  2 cm firm, non-erythematous, mobile nodule on the left forearm.
NEURO: Non-focal

We then formulated the differential diagnosis for a 69-year-old female with an aforementioned past medical history,who presented with a one month history of a left forearm nodule, and a two week history of fever, weakness, andcough.  The differential included:

1)Mycobacterium
2)Cryptococcus
3)Chlamydia PNA
4)Mycoplasma PNA
5)Legionella
6)Q-fever
7)Histoplasmosis
8)Lymphoma
9)Renal Cell CA
10)Leukemia
11)PTLD
12)HCC
13)Lung Cancer
14)Breast Cancer

Laboratory/Radiologic Data revealed:
Chem7: Na=130; K=4.2; Cl=95; HCO3=12; BUN=59; Cr=3.8; Glucose=120
CBC: WBC=25,000 (Diff. N=79, B=13), Hgb=9.8; Plt=399
UA: +2 protein
ECG:Low voltage
CXR: Multiple pulmonary nodules, and a small left pleural effusion
CT-Chest: Well-defined nodules without cavitations

Dr. Duggirala later went on to tell us that the patient’s left arm nodule was biopsied, revealing gram-positivebranching organisms consistent with the diagnosis of Nocardia infection.
I have provided the link to a review article on Norcardia, which appeared in Clinical Microbiology Reviews
http://cmr.asm.org/cgi/content/abstract/7/2/213

Compiled by Athan N. Tiliakos, D.O.
 

September 28, 2007
Presenter: Dr. Joseph Vadakara
“60-year-old male with difficulty swallowing…”
Today’s case centered on a 60-year-old male with a past medical history of cervical spine (C5-6) fusion, who presented to the ED with the complaint of “difficulty swallowing”.  The patient stated that he was in his usual state of health until three weeks prior to admission, when he began to have difficulty swallowing solid foods.  He stated that he had the sensation of food being “stuck in his chest”.  The difficulty swallowing solids quickly progressed to swallowing soft-consistency foods and liquids.  The patient denied pain, nausea, and vomiting.  He did admit to weight loss, fatigue, lethargy, and left testicular discomfort.  The patient was not taking any medications at the time of admission.  He denied the use of alcohol, tobacco, or illicit drugs.  

The Physical Exam revealed:
VITALS: T=98.4; P=60; BP=110/70; R=14
HEENT: No pallor, no icterus
NECK: No thyromegaly, no lymphadenopathy
CV: RRR S1, S2
LUNGS: Clear to auscultation bilaterally
ABD: Tenderness to deep palpation in the epigastric area.  Positive bowel sounds, heme negative.
GU: Normal prostate and left testicular vericocele.
NEURO: Non-focal
SKIN: No rashes

We then formulated the differential diagnosis for a 60-year-old male with no significant past medical history, who presented with progressive dysphagia, and was found to have epigastric pain and a left testicular vericocele.  The differential included:

1)Malignancy
a.Esophageal
b.Lymphoma
c.Gastric
d.Renal Cell CA
2)Achalasia
3)Secondary Achalasia
4)Esophageal Stricture secondary to GERD/NSAID’s
5)Eosinophilic Esophagitis

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: WBC=3.5; Hgb=13; Plt=110
LFT’s: wnl
Coags: wnl
UA: wnl
Esophogram: wnl
EGD: Mild gastritis

Dr. Vadakara later went on to tell us that the patient underwent a CT scan of his abdomen revealing a pancreatic mass invading the posterior/inferior mediastinum, as well as a splenic vein thrombosis.  The final diagnosis was metastatic pancreatic cancer. 

I have provided the link to a 2004 BMJ review article on the diagnosis of Pancreatic CA, written by Takhar et.al.

Recent developments in diagnosis of pancreatic cancer

Compiled by Athan N. Tiliakos, D.O.

September 27, 2007
Presenter: Dr. Edward Choi
“A 64-year-old male who presented with abdominal pain…”
Today’s case centered on a 64-year-old male with a past medical history of Multiple Sclerosis, who presented to the emergency room with the complaint of  “lower abdominal pain”.  The patient stated that the pain began approximately one week prior to admission.  The pain was localized to the right upper quadrant, and was described as intermittent with a dull, achy character.  There were associated light-colored stools, as well as, dark-colored urine. The patient denied fevers, chills, weight changes, HA, dizziness, chest pain, SOB, N/V, or pruritis.  The patient was taking interferon beta-1A for his MS.  He denied the use of alcohol, tobacco, or illicit drugs.  His family history was non-contributory.

The Physical Exam revealed:
VITALS: T=97.8; P=54; BP=114/76; R=16
GEN: NAD
HEENT: Positive scleral icterus, no pallor
NECK: No thyromegaly, no lymphadenopathy
CV:  RRR S1, S2
LUNGS: Clear to auscultation bilaterally
ABD: Diffusely tender, but more so in the RUQ, non-distended.  Positive bowel sounds.  Heme-negative stools.
EXT: No edema
NEURO: Non-focal
SKIN: Jaundice

We then formulated the differential diagnosis for a 64-year-old male with a past medical history of MS, who presented with a one week history of abdominal pain, light-colored stools, and dark-colored urine, who was found to be icteric and jaundiced.  The differential included:

1)Acute Hepatitis
2)Cholangiocarcinoma
3)Pancreatic Head CA
4)Metastatic Liver CA w/ ductal obstruction
5)Ductal Stone
6)Ductal Stricture
7)Lymphoma causing external compression of ducts
8)Hepatoma

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: wnl
LFT’s: Alb=3.9; AST=91; ALT=121; Alk Phos.=524; T. Bili=8.4; C. Bili=4.4
RUQ U/S: Dilation of Intra-hepatic ducts
CT-Abd: Infiltrating mass at the porta hepatis, with obstruction of the left portal vein.

Dr. Choi later went on to tell us that the patient underwent a biopsy of the lesion, which revealed evidence ofadenocarcinoma.  The presumed diagnosis was Cholangiocarcinoma.

I have provided the link to a review article in the NEJM on Multiple Sclerosis.
http://content.nejm.org/cgi/content/extract/343/13/938

Compiled by Athan N. Tiliakos, D.O.

September 20, 2007
Presenter: Dr. Missale Solomon
“51-year-old female who presents with dizzy spells for eight months…”
The patient was a 51-year-old female with a past medical history of hypertension, hypercholesterolemia, and a “heart murmur”, who presented to the ED with the complaint of “dizzy spells”.  The patient stated that the dizzy spells began 1 ½ to 2 years ago and had increased in frequency over the last few months.  The patient stated that her symptoms began as a “fainting-like” sensation, followed by numbness and tingling on the left side of her face or left arm.  The episodes would last for a few minutes, and then subside on their own.  There was also associated left-sided chest pain, but no fevers, chills, blurry vision, palpitations, cough, SOB, nausea, vomiting, or diarrhea.  The patient was taking hydrochlorothiazide, and Lipitor.  The patient had a former 10 pack year smoking history, and a distant alcohol and illicit drug use history.  Her family history was significant for maternal “heart disease” and paternal emphysema.

The Physical Exam revealed:
VITALS: T=97; P=80; BP (L) =140/83; BP(R) =156/87; R=18
GEN: No acute distress
HEENT: No pallor, no icterus
NECK: No JVD; no lymphadenopathy, no carotid bruits
CV: 2/6 pan-systolic murmur with radiation to the axilla.
LUNGS: Clear bilaterally
ABD: Soft, non-tender, non-distended, no organomegaly
EXT: No edema
NEURO: Non-focal

We then formulated the differential diagnosis for a 51-year-old female with a past medical history of hypertension, and hypercholesterolemia, who presented to the ED with the complaint of progressively worsening “dizzy spells” that were associated with left-sided facial and upper extremity numbness and tingling, as well as, left-sided chest pain.  The differential included:

1)Subclavian Steal Syndrome
2)Seizure d/o
3)TIA’s
4)Dysrryhthmias
5)Aortic dissection

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: wnl
ECG: wnl
MRA: Left subclavian narrowing with steal phenomenon.

 Dr. Solomon later went on to tell us that the patient was diagnosed with Subclavian Steal Syndrome and would undergo a stenting procedure in the near future.

I have provided the link to a very nice case presentation of this syndrome from the NEJM.
http://content.nejm.org/cgi/content/short/341/19/1458

Compiled by Athan N. Tiliakos, D.O.

September 17, 2007
Presenter: Dr. Jasmine Rafeek
“A 27-year-old male who presented with a headache for one month and a rash for two weeks…”
Today’s case involved a 27-year-old male with a past medical history of HIV that was diagnosed in 2005 (CD4 count one week prior to admission was 573), who presented to the Emergency Room with the aforementioned complaints. Apparently, the patient began to experience headaches approximately one month prior to admission.  The headaches were intermittent, located occipitally, and were made worse with movement.  These headaches were associated with neck pain, subjective fevers, chills, and night sweats.  Two weeks later the patient also began to experience a sore throat and bilateral cervical lymphadenopathy.  At that time he visited his physician who prescribed Azithromycin and Prednisone.  The patient’s sore throat improved; however, his other symptoms persisted.  One week later, the patient discovered a diffuse rash on his trunk, back, arms, legs, palms, and soles.  At that time the patient decided to seek further medical attention.  The remainder of the review of systems was negative.  He was taking Truvada and Viramune.  He denied tobacco, alcohol, or illicit drug use. 

The Physical Exam revealed:
VITALS: T=98.8; P=73; BP=111/74; 99%RA
GEN: Appeared uncomfortable
HEENT: No pallor, no icterus
NECK: Mild nuchal rigidity.  Anterior and posterior cervical lymphadenopathy
CV: RRR, S1, S2
LUNGS: Clear bilaterally
ABD: Soft, non-tender, non-distended, no organomegaly
EXT: No edema
SKIN: Diffuse, erythematous, macular/popular rash (including the palms and soles).
NEURO: Non-focal

We then formulated the differential diagnosis for a 27-year-old HIV infected male who presents with a one month history of headaches, subjective fevers, chills, and night sweats, and a two week history of cervical; lymphadenopathy and a diffuse rash (including the palms and soles).  The differential included:

1)Neurosyphilis
2)EBV
3)Rocky Mountain Spotted Fever
4)Arbovirus Infection
5)Cryptococcus
6)SLE

Laboratory/ Radiologic Data revealed:
Chem7: wnl
CBC: WBC=11.9; Hgb=15.7; Plts=350 (Diff. wnl)
LFT’s: wnl
RPR: 1:124
LP: WBC’s=<1,000; RBC’s=37, %N=22, %L=42; %M=36; Glucose=56; Protein=21;
CSF VDRL: non-reactive
CSF Cx/Stain: negative
Blood Cx: negative

Dr. Rafeek later went on to tell us that the patient was diagnosed with secondary syphilis.  The patient was started on Doxycycline, and eventually had an excellent clinical response.

I have provided the reference to a wonderful review article in the British Medical Journal.
French, Patrick, Syphilis. BMJ. 2007(334); 143-147.

Compiled by Athan N. Tiliakos, D.O.

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September 13, 2007
Presenter: Dr. Paul Kim
“A 79-year-old female who presents with weakness and unsteadiness…”
The patient was a 79-year-old female with a past medical history of paroxysmal atrial fibrillation, TIA, hypothyroidism, and psoriasis, who presented to the ED with the complaint of “weakness and unsteadiness”. Apparently, the patient’s symptoms began approximately six months ago.  Prior to these past six months, the patient was able to walk great distances and ballroom dance.  The patient stated she was able to complete her activities of daily living but with “poor coordination”.  She then began to experience generalized weakness followed by three fall episodes.  One month prior to admission, the patient then began to feel left facial numbness.  The patient was taking Amiodarone, Propafenone, Lasix, ASA, Synthroid, and Iron Sulfate.  She had a distant 48-pack-year tobacco history, but denied alcohol and illicit drug use. 

The Physical Exam revealed:
VITALS: T=98.4; P=60 regular; BP=166/77; R=12; 98%RA
GEN: NAD
HEENT: PERRLA, no pallor
NECK: no carotid bruits, positive JVD, no lymphadenopathy, no thyroid masses
CV: RRR S1, S2
LUNGS: B/L crackles at the bases
ABD: S/NT/ND, no organomegaly
EXT: Trace B/L LE edema
SKIN: Psoriatric patches on ankles, elbows, and knees
NEURO: CN’s II-XII intact, muscle strength +4/5 b/l in the upper and lower extremities, +2 reflexes throughout, intact coordination, broad-based gait, decreased temperature sensation on the left leg.

We then formulated the differential diagnosis for a 79-year-old female with an aforementioned past medical history, who presented with progressive weakness and ataxia.  The differential included:

1)Hypothyroidism
2)TIA’s
3)CVA-(Posterior circulation)
4)Folate deficiency
5)Vitamin B12 deficiency
6)Other space occupying lesion

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: WBC=5.1; Hgb=12.2; Plts=200; MCV=85
Coags: wnl
UA: wnl
LFT’s: wnl
TFT’s: TSH=3.35; FT4=0.9
VitB12: 101
Folate: 23
RPR: neg
CXR: mild cephalization

Dr. Kim later went on to tell us that the patient is scheduled for an MRI of the brain.  The presumptive diagnosis was Amiodarone toxicity vs. Vitamin B12 deficiency.

I have provided the link to a 2007 review article in the NEJM on the use of Amiodarone in Atrial Fibrillation.
http://content.nejm.org/cgi/content/short/356/9/935

Compiled by Athan N. Tiliakos, D.O.

September 10, 2007
Presenter: Dr. Omar Haq
“A 76-year-old male who presented with difficulty speaking…”
Today’s case centered on a 76-year-old male, with no significant past medical history, who presented to the ER with the complaint of “difficulty pronouncing words”.  The patient was in his regular state of health until four days prior to admission, when he began to experience difficulty with his speech, as well as, headaches.  The headaches were right-sided and were localized to the forehead with radiation to the right-side of the face.  These headaches were intermittent, and not associated with any fevers, chills, dizziness, blurry vision, photophobia, nausea, or vomiting.  There was associated weight loss (approx. 20 pounds over the last one month), dysphagia to both solids and liquids, and a tingling sensation in the upper and lower extremities bilaterally.  The patient also reported that the chronic, non-productive cough that he has had for several years had changed to hemoptysis.  He smoked two packs of cigarettes daily for 50 years, but denied the use of alcohol or illicit drugs.  His family history was non-contributory.
 
We then formulated the differential diagnosis for a 76-year-old male with a history of profound tobacco abuse, who presented with dysarthria, dysphagia, weight loss, and polyneuropathy of the upper and lower extremities.  The differential included:

1)Tumor (Primary brain vs. metastatic vs. paraneoplastic syndrome)
2)Vasculitis
3)Retropharyngeal Abscess

The Physical Exam revealed:
VITALS: T=98.6; P=95; BP=125/60; R=14; 100%RA
GEN: Appeared cachectic
HEENT: Conjunctival pallor, no papilledema
NECK: Supple, no JVD, no lymphadenopathy
CV: RRR S1, S2
LUNGS: CTAB
ABD: Soft, non-tender, non-distended.  No organomegaly
EXT: No edema
SKIN: No rashes
NEURO: Left facial droop, left deviation of the palate, left tongue deviation, no gag reflex, decreased temperature and pressure on the entire left side, positive Babinski’s on the left side, positive Romberg’s, wide-based gait, 5/5 muscle strength in the upper and lower extremities bilaterally.

Laboratory/Radiologic Data revealed:
Chem7: wnl
Calcium: 9.8
LFT’s: Protein=6.6; Alb=2.8
CBC: WBC=4.4; Hgb=11; Plts=188
UA: Trace protein
Coags: wnl
CXR: Opacity in the LUL
MRI Brain: A 4x3.5x4 cm ring-enhancing lesion in the right frontal lobe, as well as, medullary and bulbar lesions. 

Dr. Haq later went on to tell us that the lesions that were seen on MRI were thought to be consistent with metastases.  The lung opacity was biopsied and revealed evidence of NSCLC.
 
I have provided the link to a NEJM review article on Paraneoplastic Syndromes Involving the Nervous System.  Robert B. Darnell, M.D., Ph.D., and Jerome B. Posner, M.D. Paraneoplastic Syndromes Involving the Nervous System. NEJM. 2003; 349(16): 1543-1554.

http://content.nejm.org/cgi/content/short/349/16/1543

Compiled by Athan N. Tiliakos, D.O.

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September 7, 2007
Presenter: Dr. Manish Doshi
“A 53-year-old female who presents with fevers and left hip pain…”
The patient was a 53 year old Caucasian female with a past medical history of hypertension, alcohol abuse, anddepression, who presented to the ER with the complaint of fevers and left hip pain.  The patient stated that her left hip pain began four days prior to admission.  The hip pain was described as sharp, and continuous, with radiation to the buttocks.   The pain was exacerbated by movement.  Two days later, the patient developed fevers(measured to be as high as 103 deg. F), chills, weakness, and fatigue, as well as, one episode of “confusion” which lasted approximately two minutes.  The remainder of the review of systems was negative for night sweats, weight loss, HA, neck stiffness, photophobia, cough, SOB, chest pain, abdominal pain, N/V/D/C, joint pains, or rashes.  She did not have any recent dental or surgical procedures.  Her family history was not significant.  She was taking Wellbutrin and metoprolol.  She was a 25 pack year smoker, drank 3-4 glasses of vodka a day, and denied illicit drug use.  She worked as a Veterinarian’s assistant.

September 6, 2007
Presenter: Dr. Peter Chung
“61-year-old male who presents with abdominal pain…”
Today’s case centered on a 61-year-old-male with a past medical history of  ischemic cardiomyopathy with eventual heart transplantation approximately four months ago, DM-2, G6PD deficiency, hypertension, dyslipidemia, and recently treated Legionella pneumonia, who presented to the emergency room with the complaint of “abdominal pain”.  The patient was in his routine post-transplant state-of-health, until one week prior to admission, when he began to experience progressively worsening weakness, and fatigue.  Four days prior to admission, the patient began to experience diffuse abdominal pain.  The pain was described as “aching”, and “cramping” without any radiation.  The pain was intermittent, without any temporal relation to food.  One day prior to admission, the patient experienced a single episode of brown, watery diarrhea.  There were associated low-grade fevers, but no headaches, dizziness, CP, SOB, cough, palpitations, nausea, vomiting, hematemesis, hematochezia, melena, joint aches, or skin rashes.  The patient did not drink, smoke, or use illicit drugs.  At the time of admission he was taking, Cyclosporine, Prednisone, Evrolimus, Cardura, Atovaquone, Insulin pump, Toprol, and Aranesp.

The Physical Exam revealed:
VITALS: T=100.1; P=124 reg; BP=120/70; R=18; 95%RA
GEN: NAD
HEENT: No pallor, no icterus
NECK: No JVD, no thyromegaly
CV: Tachy, S1, S2
LUNGS: Clear bilaterally
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly, normal bowel sounds, heme negative
EXT: No edema

We then formulated the differential diagnosis for a 61-year-old male with a complicated past medical history including an OHT, who presented with progressive weakness, fatigue, and abdominal pain.  The differential included:

1)CMV
2)Atypical TB
3)TB
4)DKA
5)Ischemic Bowel
6)Pancreatitis
7)DKA

Laboratory/Radiologic Data Revealed:
Chem7: Na=136; K=4.1; Cl=96; HCO3=23; BUN=36; Cr=3.1; Glucose=105
Calcium: 9.2
CBC: WBC=3.5; Hgb=12.1; Plt=93
Coags: wnl
LFT’s: Alb=3.3; T. Bili=2.94; Alk Phos=78; AST=138; ALT=84
Amylase/Lipase: wnl
ECG: wnl
CXR: wnl

Dr. Chung later went on to tell us that the patient’s donor heart was positive for CMV.  A PCR for CMV revealed a viral load of 5.9 million.  The patient was diagnosed with CMV Enteritis and was started on IV Gancyclovir, with resulting clinical improvement.

I have provided a review article on post-transplant infections that was published in Clinical Microbiology Reviews.  

Clinical Microbiology Reviews, Jan 1997, 86-124, Vol 10, No. 1
Infections in solid-organ transplant recipients
R Patel and CV Paya
http://cmr.asm.org/cgi/content/abstract/10/1/86

Compiled by Athan N. Tiliakos, D.O.

September 4, 2007
Presenter: Dr. Joshua Burak
“32-year-old male who presents with a two week history of cough…”
Today’s case involved a 32-year-old Indonesian male with no significant past medical history, who presented to the ED with the complaint of cough for approximately two weeks.  The cough was preceded by a one to two month history of weakness, fatigue, and decreased energy.  These symptoms were later followed by a progressive cough.  The cough was described as “dry” and “non-productive”.  Finally, two days prior to admission the patient began to experience dyspnea, particularly with exertion.  The patient denied fevers, chills, HA, dizziness, night sweats, orthopnea, PND, hemoptysis, joint aches, rashes, or swelling.  The remainder of the review of systems was significant for a 15 pound weight loss over the last 2 months.  The patient was not taking any medications at the time of admission.  He had a 10 pack year smoking history, but denied alcohol, or illicit drug use.  The patient did admit to several unprotected sexual encounters.  His family history was significant for maternal lung CA, and paternal diabetes and hypertension. 

The Physical Exam revealed:
VITALS: T=98.5; P=74; BP=119/64; 98%RA and 88% with ambulation
GEN: Appeared in mild respiratory distress
HEENT: Conjunctival pallor, no icterus, no lymphadenopathy
CV: RRR, S1, S2
LUNGS: CTAB
ABD: Soft, non-tender, non-distended, splenomegaly, heme negative
EXT:  No edema
SKIN:  No rashes, no lesions

We then formulated the differential diagnosis for a 32-year-old male with no significant past medical history who presented with weakness, fatigue, weight loss, and a progressive cough who was found to have conjunctival pallor, and splenomegaly.  The differential included:

1)Tuberculosis
2)Endocarditis
3)Lymphoma
4)HIV
5)Other deep-seeded infection

Laboratory/Radiologic Data revealed:Chem7: wnl
CBC: WBC=4.9 (Diff.: N=62%; B=12%; L=17%; M=4), Hgb=8.4; Plt=293
MCV: 64.1
Coags: wnl
LFT’s: wnl
Alb: 2.7
LDH: 312
Hgb Electrophoresis: Findings consistent with beta-thalassemia
CXR: Diffuse interstitial process
CT-scan Chest: Evidence of pulmonary hypertension with a diffuse interstitial process

Dr. Burak later went on to tell us that the patient underwent a bronchoscopy that revealed evidence of PCP pneumonia.  The patient was also found to have a positive HIV test, and a CD4 count of 7.  The final diagnosis was Beta-Thalessemia and AIDS.

I have provided the link to a 2005 review article on Beta-Thalassemia that was published in the NEJM.

http://content.nejm.org/cgi/content/extract/353/11/1135

Compiled by Athan N. Tiliakos, D.O.

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August 31, 2007
Presenter: Dr. Jeffrey Aversa
“A 62-year-old male who presents with abdominal pain for three months…”
Today’s case centered on a 62-year-old male with a past medical history of a heart transplant in 1987 (unknown etiology of precipitating heart disease), squamous cell CA of the skin, PUD, glaucoma, and chronic neck pain, who presented to the ED with the complaint of abdominal pain.  The patient stated that the abdominal pain began approximately three to four months ago, and had progressively worsened.  The pain was initially described as intermittent, dull, and crampy that eventually became constant and more severe.  The abdominal pain seemed to have worsened approximately 20-30 minutes after a meal.  There were associated subjective fevers (particularly at night), a twenty pound weight loss, early satiety, decreased appetite, and abdominal distension.  The patient denied HA, dizziness, CP, SOB, orthopnea, PND, N/V/D, dysphagia, melena, hematochezia, jaundice, or pruritis.  A colonoscopy done five years earlier was grossly normal.  The patient was taking Cyclosporine, Imuran, Prednisone, captopril, nifedipine, Pravachol, ibuprofen, extended release MSO4, and Protonix.  The patient denied the use of alcohol, tobacco, or illicit drugs.  His family history was significant for two sons who had sudden cardiac death.

The Physical Exam revealed:
VITALS:  T=98.3; P=75; BP=108/69; R=18; 99%
GEN: NAD
HEENT: No pallor, no icterus
NECK: No JVD, normal thyroid size and contour, no LA
CV: RRR, S1, S2
LUNGS: CTAB
ABD: Soft, diffuse tenderness (particularly in the LLQ), positive distension, positive bowel sounds, hepatomegaly, and heme negative stool.
GU: Prostate was firm and enlarged
EXT: No edema
NEURO: Non-focal.

Laboratory/Radiologic Data revealed:
Chem7: Na=137; K=4.2; Cl=96; HCO3=31; BUN=29; Cr=2; Glucose=121
Calcium: 10.1
Albumin: 3.2
LFT’s: wnl
Amylase/Lipase: wnl
CBC: WBC=7.8; Hgb=13.4; Plt=369

We then formulated the differential diagnosis for a 62-year-old male with a past medical history of an OHT in 1987, squamous cell skin CA, and PUD who presented with progressively worsening abdominal pain, weight loss, and early satiety who was found to have diffuse abdominal pain, hepatomegaly, and evidence of distension.  The differential included:

1)MALT
2)Post-transplant lymphoproliferative disorder
3)Gastric CA
4)Pancreatic CA
5)Melanoma
6)CMV
7)EBV
8)Toxo
9)TB

Dr. Aversa later went on to tell us that the patient underwent an obstruction series that revealed dilated loops of bowel with evidence of large amounts of stool.  A CT scan of the abdomen was then performed, revealing a large peri-aortic mass, as well as, evidence of diffuse lymphadenopathy.  Biopsies were later performed, showing diffuse large B-cell type lymphoma.

I have provided the link to a review article on "Post-Transplant Lymphoproliferative Disorder" from the Critical Reviews of Oncology/Hematology.  During today’s case, we also had the opportunity to discuss the sign of Lesser-Trelat (“explosive” onset of seborrheic keratoses that is usually associated with neoplasms of the GI tract,breast, lung and lymphoid tissues).  I have provided the link to a wonderful review article, written by Kurzrock et. al., on "Cutaneous Paraneoplastic Syndromes in Solid Tumors", that was published in the American Journal of Medicine in 1995.

Post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation.  Critical Reviews in Oncology/Hematology, Volume 56, Issue 1, Pages 155-167 A. TAYLOR, R. MARCUS, J. BRADLEY
http://linkinghub.elsevier.com/retrieve/pii/S1040842805000934

Cutaneous paraneoplastic syndromes in solid tumors.  The American Journal of Medicine, Volume 99, Issue 6, Pages 662-671 R. Kurzrock
http://linkinghub.elsevier.com/retrieve/pii/S000293439980254X


Compiled by Athan N. Tiliakos, D.O.

August 28, 2007
Presenter: Dr. Michael Adenaike
“44-year-old male who presents with dizziness and pre-syncope…”
The case presented today involved a 44-year-old African-American male with no significant past medical history, who presented to the ED with the complaint of “dizziness” and the sensation of “wanting to pass out”.  The patient’s symptoms began approximately three weeks prior to admission.  At that time he began to feel progressively worsening fatigue and SOB with his activities of daily living.  He also reported subjective fevers, a “throbbing” sensation in his head, gingival pain, tinnitus, palpitations, a twenty pound weight loss, and left upper quadrant abdominal pain.  On   the day of admission, the patient was reaching for something on a high shelf, and began to feel that he was going to “pass out”.  The patient then had a witnessed fall.  There was no trauma, loss of consciousness, or loss of bowel/bladder continence.  The patient was not taking any medications.  He admitted to marijuana use, but denied alcohol or tobacco use.  His family history was non-contributory,

The Physical Exam revealed:
VITALS: T=98.8; P=95; BP=126/60; R=18; 100%RA
GEN: NAD
HEENT: Pale conjunctiva, gingival hyperplasia
NECK: No lymphadenopathy, no thyromegaly
CV: RRR S1, S2
LUNGS: Clear
ABD: Soft, non-tender, splenomegaly
EXT: No edema
NEURO: Non-focal

We then formulated the differential diagnosis for a 44-year-old African-American male who presents with weight loss, fatigue, dizziness, tinnitus, and gingival pain who was also found to have pallor, gingival hyperplasia, and splenomegaly.  The differential included:
1) AML
2) Myeloproliferative disorder
3) Hyperviscosity syndrome
4) MM
5) Waldenstrom’s
6) Menieres Disease

Laboratory/Radiologic data revealed:
Chem10: wnl
CBC: WBC=42.7 (Diff.= 72% Blasts; 11% Neuts; 9% Lymphs); Hgb=5; Plts=46
Peripheral Smear: Findings consistent with AML (Auer Rods)

Dr. Adenaike later went on to tell us that the patient was finally diagnosed with AML M4 subtype.  I have provided the link to a review article that was published in the Mayo Clinic Proceedings by Dr. Elias Jabbour et. al.
Adult Acute Myeloid Leukemia
http://www.mayoclinicproceedings.com/pdf%2F8102%2F8102sophm.pdf

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August 24, 2007
Presenter: Dr. Nina Cheung
“A 57-year-old female who presents with abdominal pain for five days…”
Today’s Morning Report centered on a 57-year-old female with a past medical history of kidney stones, and a cholecystectomy done in 1992, who presented to the ER with the complaint of abdominal pain.  The patient stated that her abdominal pain began approximately five days ago, and was located predominately in the right upper quadrant. The pain was described as “cramping-like” with a sensation of "pressure".  The pain was intermittent, apparently waxing and waning every 15 minutes.  There was associated nausea and vomiting, particularly minutes after eating meals.  Upon a further review of the patient’s symptoms, it was discovered that the she was also experiencing subjective fevers, chills, decreased appetite, and dark-colored urine.  She denied any symptoms of dysphagia, CP, cough, SOB, hematemesis, diarrhea, melena, skin rashes or joint aches.  She was taking a daily multi-vitamin, as well as, Zyrtec.  The patient denied tobacco, alcohol, or illicit drug use, and lived in a homeless shelter.  Her family history was non-contributory.

The Physical Exam revealed:
VITALS: T= 98.4; P=94; BP=130/88; R=16; 100%RA
GEN: Appeared uncomfortable
HEENT: No pallor, no conjunctival icterus
CV: RRR S1, S2
LUNGS: Clear bilaterally
ABD: Soft, positive bowel sounds, tenderness to palpation over the RUQ, positive Murphy’s sign, positive guarding without rebound over the RUQ, palpable liver edge with a total liver span of 17cm.  The stool was negative for occult blood.
SKIN: No jaundice
NEURO: Non-focal

This led us to formulate the differential diagnosis for a 57-year-old female with a past medical history of a previous cholecystectomy, who presented with intermittent right-sided abdominal pain, and was found to have tenderness to palpation over the RUQ and hepatomegaly.  The differential included:

1)Common Bile Duct Stone
2)Acute Hepatitis (most consistent with Hep. A)
3)EBV
4)CMV
5)Fitz-Hugh Curtis Syndrome
6)Autoimmune hepatitis
7)Pancreatic Pseudocyst

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: WBC=17.8 (Differential consistent with a ‘left shift”), Hgb=12.4
LFT’s: T. Bili=2.3; D. Bili=1.15; Alk. Phos=298; AST=147; ALT=208; GGT=408
Coags: wnl
CT-Abd: Moderate intra/extra hepatic ductal dilatation, possible ampullary stricture,and evidence of cholangitis

Dr. Cheung later went on to tell us that after the CT scan results, the patient was started on levofloxacin and metronidazole.  The patient then underwent an ERCP which revealed evidence of a Common Bile Duct stone. 

I have provided the link to a wonderful review article on gallstone disease, written by I.J. Beckingham, which was published in a 2001 edition of the British Medical Journal.

Gallstone Disease
http://www.bmj.com/cgi/content/extract/322/7278/91

Compiled by Athan N. Tiliakos, D.O.

August 23, 2007
Presenter: Dr. My Padmalingam
“49-year-old female who presents with shortness of breath and rectal bleeding…”
Today’s case involved a 49-year-old African-American female with a past medical history of low back pain, who presented to the ED with the complaint of shortness of breath and blood in her stools.  The patient stated that her shortness of breath began approximately two weeks prior to admission.  Initially, the shortness of breath was worsened with exertion, but progressed to the point that she was short of breath even at rest.  One week prior to admission, the patient was experiencing increased frequency of loose stools (3-4 times per day), that eventually became “blood tinged”.  The patient also admitted to significant weight loss over the last month, as well as increased lower back pain.  The patient denied fevers, chills, night sweats, change in appetite, dizziness, cough, chest pain, palpitations, abdominal pain, nausea, vomiting, odynophagia, joint pains, or skin rashes.  She had no sick contacts.  She was currently unemployed.  Her social history was significant for a 74 pack year smoking history, heavy alcohol use, and no illicit drug use.  Her family history was significant for melanoma (father-deceased), and liver cirrhosis secondary to alcoholism (mother-deceased).  Percocet was the only medication that she was taking at the time of admission. 

The Physical Exam revealed:
VITALS: T=98.4; P=89; BP=144/83; R=20; 95% on RA
GEN: Appeared fatigued
HEENT: No pallor or icterus
NECK: 2cm x 1cm fixed, rough-textured, right-sided, anterior cervical lymph node.
CV: Grade 3/6 holosystolic murmur heard loudest over the LSB
LUNGS: Decreased breath sounds at the left base with significant dullness to percussion
ABD: Large reducible ventral hernia, no hepato-splenomegaly.  Rectal exam revealed bright red blood mixed with green stool.
EXT: no edema
BREAST: Painful left-sided axillary node. 2 cm mass in the left breast located superior to the areola.  There was evidence of skin retraction
NEURO: Non-focal

This led us to formulate the differential diagnosis for a 49-year-old female with a past medical history of low back pain who presented with progressively worsening shortness of breath and bright red blood per rectum and was found to have anterior cervical lymphadenopathy, a lung exam that was consistent with significant effusion, and an ominous breast exam.  The differential included:

1)Metastatic Breast CA
2)Metastatic Lung CA
3)Melanoma

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: Hgb=12.1, Plt’s=527
Calcium=9.8
Coag’s: wnl
CXR: “white-out” of the left lung with tracheal deviation to the right.

Dr. Padmalingam later went on to tell us that the patient underwent a diagnostic/therapeutic thoracentesis.  The cytology was consistent with breast CA.  Biopsy of the neck mass revealed findings consistent with breast CA that was further characterized as ER negative, PR positive, and Her-2-neu negative.  The patient’s BRBPR was apparently secondary to isolated colitis of the sigmoid colon.

I have provided a link to the National Comprehensive Cancer Network’s practice guidelines for Breast Cancer.
http://www.nccn.org/professionals/physician_gls/PDF/breast-screening.pdf

Compiled by Athan N. Tiliakos, D.O.

August 21, 2007
Presenter: Dr. Sudhir Vyakaranam
“39-year-old African American female who presents with hemoptysis…”
Today’s case involved a 39-year-old African American female with a past medical history of sarcoidosis (diagnosed by a skin biopsy), pulmonary hypertension (diagnosed in 2005), and seasonal allergies, who presented to the emergency room with the complaint of “coughing up blood.”  Apparently, the patient’s symptoms began four months earlier, with the onset of episodic fevers.  These fevers occurred once or twice per week, and were measured to be as high as 102 deg. F. The fevers were associated with night sweats, profound lethargy and fatigue, cough with green-colored sputum, and increased SOB from baseline.  These symptoms led the patient to visit a local outside hospital, where the diagnosis of community-acquired pneumonia was made.  The patient’s symptoms seemed to have briefly improved after the treatment of the pneumonia.  Four weeks prior to admission, the patient’s previous symptoms reappeared.  Finally, one day prior to admission, the patient began to experience frank hemoptysis.  At the time of admission, the patient was taking prednisone, bosentan, and oxygen.  She had a distant smoking history, and denied the use of alcohol or illicit drugs.  She worked in a nursing home as a nurse’s assistant.

The physical exam revealed:
VITALS: T=100.1; P=96; BP=128/88; R=18; 98% on 2L
GEN: Appeared in distress, and cachectic
HEENT: Conjunctival pallor
NECK: Increased JVD
LUNGS: Decreased breath sounds at the bases, inspiratory wheezes at the apices bilaterally
CV: RRR, S1, S2; Systolic murmur consistent with TR
EXT: Trace pedal edema, no clubbing
LN: No lymphadenopathy
NEURO: Non-focal

We then formulated the differential diagnosis for a 39-year-old female with a past medical history of sarcoidosis (on long-term steroids), and pulmonary hypertension who presents with fevers, fatigue, night sweats, cough, and hemoptysis.  The differential included:

1) Tuberculosis
2) MAI
3) Aspergillosis
4) Malignancy
5) Vasculitis
6) PE
7) Cryptogenic Organizing Pneumonia (formerly BOOP)

Laboratory/Radiologic data revealed:
Chem7: wnl
CBC: WBC=10.2; Hgb=10.6; Plt=330
Coags: PT=15.5; PTT=39.2; INR=1.17
CXR: Alveolar hemorrhage pattern, potential cavitary lesions
CT Chest: Cavitary lesions consistent with aspergilloma in the right mid lung field.
Bronchoscopy: BAL specimens grew Aspergillus species.

Dr. Vyakaranam later went on to tell us that the patient continued to have massive hemoptysis, which required intubation and an embolization procedure by Interventional Radiology.  The patient later coded and eventually passed away.  The final diagnosis was pulmonary aspergilloma.

I have provided the link to a review article authored by doctors Soubani and Chandrasekar, entitled “Clinical Spectrum of Pulmonary Aspergillosis” that appeared in a 2002 issue of Chest. http://www.chestjournal.org/cgi/content/full/121/6/1988

 Compiled by Athan N. Tiliakos, D.O.

August 20, 2007
Presenter: Dr. Vamsee Yaganti
“41-year-old African American female who presents with the complaint of abdominal pain…”
Today’s case concerned a 41 year old African American female with a past medical history of HIV (last CD4 count of 267, not on any HAART), depression and recently diagnosed anemia, who presented to the ED with the complaint of abdominal pain.  The patient stated that the pain began one month ago, and had progressively worsened over time.  The pain was described as constant, and sharp/stabbing in nature.  The pain worsened with eating and positional changes.  There was associated weight loss (approx.15 pounds over the last month), night sweats, chills, sore throat, pain with swallowing, nausea/vomiting, and back pain.  The patient denied fevers, chills, HA, dizziness, CP, SOB, cough, diarrhea, constipation, or dysuria.  Two weeks prior to admission, the patient visited her internist’s office and was found to be anemic with a hemoglobin of 7.  The patient was taking Risperdal.  She denied the use of alcohol or illicit drugs, but admitted to a 10 pack year history of tobacco.  Her family history was significant for maternal hypertension.

The physical exam revealed:
VITALS: T=98.1; P=127; BP=114/60; R=16; 97%RA
GEN: Mild to moderate distress secondary to pain
HEENT: conj. Pallor, and oral-pharyngeal thrush
LN: Mobile 2x2 cm left axillary, non-tender LN
LUNGS: CTAB
CV: 2/6 systolic murmur heard loudest at the left sternal border
ABD: LU, and LLQ tenderness to palpation, pos. rebounding, pos. guarding, pos. bowel sounds, pos. splenomegaly, left CVA tenderness, stool negative for occult blood.
NEURO: Non-focal

This led us to formulate the differential diagnosis for a 41-year-old female with a past medical history that is significant for HIV (CD4=267), who presented with abdominal pain and anemia, and was found to have oral thrush, significant LA, left sided abdominal tenderness, and splenomegaly.  The differential included:

1) TB
2) CMV
3) EBV
4) Endocarditis
5) Fungal Infxn
6) Lymphoma
7) Leukemia
8) Breast CA

Laboratory/Radiologic Data revealed:
Chem7: wnl
CBC: WBC=11.6 (N=74%, L=18%, M=10%); Hgb=7; Plt=607
Iron Studies: evidence of iron deficiency
LDH: 561
Peripheral Smear: Megakaryocytes, burr cells, tear drops, schistocytes
CXR: Clear
CT Abd: Thickening of the gastro-esophageal mucosa, with evidence of diffuse lymphadenopathy, as well as several necrotic lymph nodes.
EGD: Large mass in the stomach.

Dr. Yaganti later told us that the stomach mass was biopsied, revealing B-cell lymphoma.

Anemia is the most common hematologic manifestation in AIDS patients, affecting 60-80% of patients.  There are several etiologies associated with anemia.  These include:
A. Infections
1) Mycobacteria and fungi including MAC, TB, and Histo. The mechanism most often involves bone marrow infiltration.
2) Viral infections, such as, CMV, EBV, and Parvovirus B19.  The mechanism again involves bone marrow suppression.
B. Malignancies such as lymphomas are able to invade the bone marrow.
C. Nutritional deficiencies through several mechanisms may contribute to anemia through the lack of bio-availability of the building blocks required for hematopoiesis.
D. Abnormal Iron Metabolism
E. Hemolysis ( Antibody mediated, drug induced, or direct effects of HIV).

Information obtained from Timothy Friel’s and David Scadden’s wonderful article "Hematologic Manifestations of HIV:Anemia" on UpToDate.

Compiled by Athan N. Tiliakos, D.O.

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August 17, 2007
Presenter: Dr. Chi Tai Chung
“61-year-old male who presents with abdominal pain…”
Today’s case centered on a 61-year-old male, with no significant past medical history, who presented to the emergency room with the complaint of abdominal pain.  The pain began approximately three months ago, and was localized to the R lower and L upper quadrant.  The pain was described as intermittent, sharp in nature, and was exacerbated by movement.  There was associated loss of appetite, a 40 pound weight loss, early satiety, black colored stools, and constipation for two months.  The patient also reported pencil-thin caliber stools.  There were no associated fevers, chills, weakness, dizziness, chest pain, SOB, cough, or N/V/D.  The patient was a 25 pack year smoker, but denied alcohol, or illicit drug use.  He was on no medications, and had not had any routine health maintenance. We then formulated a differential diagnosis for a 61-year-old male with no significant past medical history who presented with abdominal pain for three months, associated with significant weight loss, melena, and early satiety. The differential included:

1) Colon CA
2) Lymphoma
3) Tuberculoma
4) Typhlitis
5) Yersinia
6) Amoebiasis
7) Appendicitis
8) Inflammatory Bowel Disease

The physical exam revealed:
VITALS: T=99.3; P=118; BP=134/67; R=18; 99%
GEN: Appeared in no acute distress
HEENT: Non-icteric, no pallor
LUNGS: Clear to auscultation
CV: Tachycardic, S1, S2, no murmurs
ABD: Firm, tender in the right and left lower quadrant, guarding in the RLQ, and a large palpable mass in the RLL.
LN: B/L mobile inguinal lymph nodes
EXT: No clubbing, no cyanosis, no edema

Laboratory/Radiologic Data Revealed:
Chem7: wnl
CBC: WBC=13.6; Hgb=12
Obst Series: Evidence of free air under the diaphragm
CT-Abd/Pelvis: Large cecal mass with luminal narrowing and mets throughout the abdomen and peritoneum. 

The final diagnosis was Stage IV Metastatic Adenocarcinoma of the Colon.
I have provided the link to a review article in a 2006 issue of the NEJM pertaining to adenomatous polyps.

Adenomatous Polyps of the Colon
http://content.nejm.org/cgi/content/extract/355/24/2551

 Compiled by Athan N. Tiliakos, D.O.

 August 16, 2007
Presenter: Dr. Kalyani Meduri
“78-year-old male who presents with the complaint of fevers…”
Today’s case involved a 78-year-old male with a past medical history of hypertension, DM-2, hypercholesterolemia, GERD, BPH, recently discovered lupus anticoagulant, peripheral neuropathy, dementia, glaucoma, and diverticulitis, who presented to the emergency room with the complaint of fevers.  The patient stated that the fevers began approximately 3 months ago. These fevers occurred intermittently 2 to 3 times per week. The fevers were measured as high as 101 degrees F. During this time, the patient was also experiencing the associated symptoms of loss of appetite, weight loss (20 pounds), chills, diaphoresis, and diffuse abdominal pain, as well as several episodes of hypoglycemia. The patient was a former smoker and denied the use of alcohol or illicit drugs. His family history was non-contributory. At the time of admission, the patient was taking: ASA, Neurontin, Lipitor, Iron Sulfate, Flomax, Glipizide, and Lisinopril.

We then formulated the differential diagnosis of a 78-year-old male with the aforementioned medical history who presented with intermittent fevers that were associated with significant weight loss, abdominal pain, and several episodes of hypoglycemia. The differential included:

MALIGNANCY:
1) Lymphoma
2) Multiple myeloma
3) CLL
4) Renal cell CA
INFECTION:
1) TB
2) Endocarditis
3) Deep-seeded abscess
CONNECTIVE TISSUE DISEASE
1) Vasculitis
2) SLE

The physical exam was unremarkable other than for a fever of 101 degrees F, as well as evidence of sensory and motor deficits in the feet bilaterally.

Laboratory/Radiologic Data revealed:
Chem 10: wnl
CBC: WBC=7.8; Hgb=10.8; Plt’s=688
Coags: elevated PTT=53
ESR: >100
2D ECHO: nl EF; RVSP=70; enlarged pulmonary artery
PPD: negative
CXR: normal
CT-Chest/Abdomen/Pelvis: Multiple calcified left hilar and sub-carinal lymph nodes, with diffuse lymphadenopathy in the abdomen, and some thickening of the gastric mucosa

Dr. Meduri later went on to reveal that the patient underwent EGD and U/S guided biopsy of a peri-gastric lymph node. The biopsy results led to the decision to undergo a bone marrow biopsy, which revealed Reed-Sternberg cells consistent with Hodgkin’s lymphoma. The final diagnosis was nodular sclerosis type Hodgkin’s lymphoma.

This patient had apparently previously undergone an extensive workup for his fevers. I have provided a link to a review article on the evaluation of fever of unknown origin in the geriatric population that was published in the journal Geriatrics in 2004.

Fever of Unknown Origin — Keys to Determining the Etiology in Older Patients
http://geri.com/geriatrics/data/articlestandard//geriatrics/422004/128364/article.pdf

Compiled by Athan N. Tiliakos, D.O.

 August 14, 2007
Presenter: Dr. Peter Chung
“31-year-old female who presents with chest pain for two weeks…”
The patient presented today was a 31 year old Chinese female with no significant past medical history, who presented to the emergency room with the complaint of right sided chest pain for two weeks. The pain began gradually, and had progressively worsened. The patient localized her symptoms to the right anterior chest wall. The pain worsened with deep inspiration, and upon lying down in the lateral decubitus position. There was no radiation of her chest pain. The patient reported new-onset non-productive cough that occurred with deep inspiration, as well as, shaking chills, and myalgias. The patient denied weight loss, night sweats, weakness, dizziness, SOB, abdominal pain, nausea, vomiting, diarrhea, or skin rashes.  One day prior to admission, the patient reported worsening of her chest pain and subjective fevers leading her to visit the ED.  While in the ED, the female underwent a chest x-ray, and was told to follow up the next day.  The next day, the patient re-visited the ED because of continued fevers and chest pain.  The patient was not taking any medications.  She denied any alcohol, tobacco, or IV drug abuse.  She worked as a researcher in a laboratory involved with HIV. Her family medical history was non-contributory.

We then formulated the differential diagnosis for a 31-year-old Chinese female with no significant past medical history who presented with pleuritic type chest pain, fevers, cough, and myalgias. The differential included:

1) Tuberculosis
2) Atypical Pneumonia
3) Parapneumonic effusion vs. Empyema
4) Serositis from CTD
5) Vasculitis
6) Liver abscess
7) Pulmonary Embolus
8) Malignancy

The physical exam revealed:
VITALS: T=102.6; P=114; BP=82/66; R=18; 99%RA
GEN: Toxic appearing
HEENT: No scleral icterus, no conjunctival pallor
NECK: No JVD
CV: Tachycardic
LUNGS: Decreased breath sounds at the right base.  Dullness to percussion at the right base.
ABD: Benign
EXT: No edema
SKIN: No rashes
NEURO: Non-focal

Laboratory/Radiologic data revealed:
Chem7: Sodium=129; Potassium=3.6; Chloride=102; Bicarb=20; BUN=7; Creat=0.6; Gluc=89
CBC: WBC=5.7; Hgb=12.1; Plt=268 (Diff revealed a left shift)
LFT’s: wnl
UA: wnl
CXR: Right pleural effusion, evidence of loculated fluid in the fissures, left upper lobe patchy infiltrates
Thoracentesis: Evidence of an exudative effusion
CT Chest: “Tree in bud” appearance on the left side
Bronchoscopy: BAL washings and sputum samples revealed negative AFB smears.

Dr. Chung later went on to tell us that despite the negative AFB smears, the suspicion for TB was very high.  The patient was sent home on a four drug regiment.  A few weeks later, the sputum cultures grew Mycobacterium tuberculosis. 

In the June 2007 issue of Chest, Dr. Ajit Lalvani reviewed the relatively recent T-cell based interferon gamma release assays and their role in the diagnosis of active and latent tuberculosis. The two main assays that were reviewed include the ELISpot assay, which counts antigen specific T cells, and the ELISA test which measures interferon gamma concentrations of whole blood specimens.  Dr. Lalvani references several studies which determined that both tests (when compared to culture-confirmed TB) are more sensitive than tuberculin skin testing, but the sensitivity of the ELISpot test is higher than that of the ELISA test (83-97% sensitivity vs. 70-89% sensitivity respectively).   Unfortunately, in the diagnosis of latent TB infection, these tests have proved to be difficult to interpret since there is no real valid “gold standard” in the diagnosis of latent TB.

Source:
Lalvani A. Diagnosing Tuberculosis Infection in the 21st Century. Chest. 2007; 131:1898-1906.

Compiled by Athan N. Tiliakos, D.O.

 August 13, 2007
Presenter: Dr. Bilal Sarwar
“15-year-old female who presents with painful, blackened toes...”
Today’s case centered on an unfortunate 15-year-old Pakistani female with no significant past medical history, who was transferred to a regional hospital from her village with the complaint of a two-week history of painful “blackened toes.”  The case began approximately 4 years ago when the patient began to experience prolonged episodes of fever, associated with joint pains.  The patient was treated with a two-week course of penicillin with subsequent resolution of her symptoms.  Four years later (i.e., the time of presentation), the patient again began to experience low to mid grade fevers over a period of five months.  The fevers were associated with a 15-pound weight loss, rigors, night sweats, joint pains, and a three-day window of expressive aphasia which spontaneously resolved. Again, the patient was given PCN with resulting temporary defervescence.  Two weeks prior to presentation, the patient began to experience toe pain.  Initially, the toe pain began on the right foot, but later spread to the left as well.  The toes became red, tender, and later turned a dark/black color.  The patient took over-the-counter aspirin for the pain.  The review of systems was otherwise negative.  The patient was not on any medications at the time of presentation.  Her family history was significant for hypertension and diabetes.  The social history was non-contributory.  

The physical exam revealed:
VITALS: T=102; P=98; BP=85/50; R=16; 98%
GEN: Irritable, apparent distress
HEENT: conjunctival pallor
NECK: Supple, no masses
LUNGS:  Clear to auscultation
CV:  Soft S1, S2, grade 4/6 holosystolic murmur with radiation into the axilla.  Mid-diastolic murmur heard over theLSB.  Normal carotid pulses.  Palpable lower extremity pulses bilaterally.
NEURO: Non-focal exam
EXT: No upper extremity clubbing or cyanosis.  The finger nails had evidence of “red streaking”. There were palpable tender, nodules on the palmar sides of the digits B/L.  All the toes on the right foot and 3 toes on the left footwere gangrenous.

This led us to formulate the differential diagnosis for a 15-year-old female with a medical history significant for fevers, and joint pain who now presents with fevers, weight loss, resolved expressive aphasia, a high grade systolic murmur, a diastolic murmur, possible evidence of splinter hemorrhages, tender nodes on the digits of both hands, and gangrenous toes.  The differential included:

1) Endocarditis
2) Rheumatic Fever
3) Vasculitis
4) Atrial Myxoma

Laboratory/ Radiologic data revealed:
Chem 7=wnl
CBC: WBC=14.9; Hgb=12, PLT’s=204
Coags: wnl
LFT’s: wnl
ECG: NSR; Significantly increased PR interval
CXR: grossly normal
2D ECHO: Estimated EF of 50%; Severe MR, AR; Multiple vegetations on the valve leaflets; septal abscess with mitralring dilatation
Blood Cx: PCN resistant Streptococcus viridans Endocarditis.

Dr. Sarwar later went on to explain that the patient became hemodynamically unstable from presumptive septic shock and died before any surgical intervention could be initiated.  The final diagnosis was PCN resistant Streptococcus viridans Endocarditis.

During the morning report presentation, the issue of when to surgically intervene in endocarditis was discussed.  A recent clinical review of Infective Endocarditis in the British Medical Journal by Beynon, Bahl, and Prendergast presented six clinical factors that necessitated the urgent use of surgical intervention.  These factors included:
1) Hemodynamic instability
2) Fevers despite antibiotics
3) Abscesses or extravalvular infectious spread of the organsism
4) Evidence of aggressive drug resistant organisms
5) Endocarditis affecting prosthetic valves
6) Vegetations measuring more than 10 mm.

Source:
Beynon R, Bahl VK, Prendergast BD.  Infective Endocarditis.  British Medical Journal . 2006; 333(7563):334-9.

Information compiled by Athan N. Tiliakos, D.O.

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 August 10, 2007
Presenter: Dr. Jasmine Rafeek
“81-year-old female who presents with the complaint of worsening shortness of breath…”
The patient discussed today was an 81-year-old female with a past medical history of hypertension, COPD, osteoarthritis, diverticulosis, “bladder cancer,” carotid atherosclerosis s/p bilateral CEA, and a recent pericardial window for a moderate pericardial effusion, who presented to HUH with the complaint of subjective fevers, increased shortness of breath, fatigue, and cough. Apparently the patient had presented to an outside hospital approximately 1.5 months ago with similar complaints. At that time a workup of her symptoms revealed evidence of a right lower lobe infiltrate on CT chest. A 2D echocardiogram revealed a mild pericardial effusion.  A pericardial window/biopsy was then performed. The fluid analysis and biopsy specimens were consistent with chronic inflammation. After the procedure and the treatment for presumed community acquired pneumonia was initiated, the patient’s symptoms began to improve. The patient was feeling well for approximately two weeks after discharge. Two weeks later, she began to experience the same symptoms that previously led her to initially seek medical attention at the outside hospital. The patient stated that her shortness of breath was mostly at rest. She denied orthopnea or PND. The remainder of the review of systems (other than the presenting complaints) was essentially negative. The patient was taking labetolol, Diovan, Singulair, Zocor, Xanax, Duonebs, Pulmicort, Fosamax, calcium, and vitamin D. She had a >50 pack year smoking history. She denied alcohol or illicit drug use. Her family history was significant for maternal coronary artery disease. This led us to formulate the differential diagnosis for an 81-year-old female with an aforementioned past medical history who presents with progressive SOB, subjective fevers, fatigue and cough approximately two months after undergoing a pericardial window. The differential included:

1) Malignancy
2) Serositis secondary to connective tissue disease
3) Empyema
4) Infection after instrumentation
5) Uremia
6) TB
7) Hypothyroidism
8) PE

The physical exam revealed:
VITALS: T=100.5; P=95; BP=110/40; R=18; 94% RA; No pulsus paradoxus
GEN: Anxious
HEENT: Conjunctival pallor
NECK: 11cm JVD
LUNGS: Diffuse coarse breath sounds, with decreased breath sounds at the bases.  Dullness to percussion at the bases
CV: Distant heart sounds.  Diffuse pan-systolic heart murmur.  No evidence of pericardial rub. 
ABD: Benign
EXT: No peripheral edema
NEURO: Non-focal
SKIN: No rashes

Laboratory/Radiologic data revealed:
Chem 7: Essentially normal
CBC: WBC=18.4; Hgb=8.1, Plt=470 (Left shift on the diff)
CXR: Cardiomegaly, B/L pleural effusions on the L>R with evidence of atelectasis vs. consolidation
2D ECHO: Moderate antral/lateral effusions.  Right atrial collapse with tamponade physiology.
Right Heart Catheterization:
 RA= 4
 RV=32/10
 PA=32/6
 Wedge=9
 C.I.=4.1
 C.O.=5.75
Dr. Rafeek later went on to reveal that the patient had an unsuccessful pericardiocentesis. A repeat pericardial window/drainage was performed by CT surgery. The fluid analysis and biopsy specimens are pending.  I have provided the link to a review article on Pericardial Disease in Circulation. I have also provided the bibliography of a pertinent article in JAMA.

Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007, Apr 25; 297(16):1810-8. http://circ.