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46 yr old woman with asthma and rightsided paresthesias

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66 yo Asian woman with long-standing history of asthma presents ... Prodrome: atopy, asthma, allergic rhinitis. Eosinophilic phase. Vasculitis. Asthma = 95 ... – PowerPoint PPT presentation

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Title: 46 yr old woman with asthma and rightsided paresthesias


1
46 yr old woman with asthma and right-sided
paresthesias
  • Anh Innes

2
History
  • 66 yo Asian woman with long-standing history of
    asthma presents with right-sided weakness and
    paresthesias.
  • 5 d PTA pt noted sx in RLE, then in RUE
  • weakness, decreased sensation, and pain
  • 1 previous episode of b/l LE paresthesias 1 year
    ago
  • ROS mild wheezes, SOB (no change from
    baseline) weight loss (10 lbs/3-4 mos)

3
History, cont.
  • PMH
  • Asthma
  • Allergic rhinitis
  • DM type 2
  • Hx Graves disease
  • Breast mass s/p FNA
  • PPD (Ø tx)
  • ? cholesterol
  • Meds
  • Flovent 220 mcg
  • Serevent
  • Singulair 10 mg qd
  • Prednisone 10 mg qd
  • Nasocort
  • Albuterol MDI prn
  • Glyburide
  • Pravastatin
  • alendronate

4
History, cont.
  • Social
  • China to SF 1979
  • Lives alone
  • Denies tob/Etoh/IDU
  • Ø pets/birds/mold/
  • mildew

5
Exam
  • 37.6 130/65 91 18 96 RA
  • Elderly Asian woman, supine in bed, NAD
  • No thyromegaly
  • Diffuse, mild expiratory wheezes without rhonchi
    or crackles
  • Neuro exam
  • Motor 3/5 RUE and RLE distal 4/5 RUE and RLE
    proximal R foot drop
  • Sensory decreased sensation RLE distal lateral
    distribution and dorsum of foot

6
(No Transcript)
7
Data, cont.
  • 13.1
  • 20.1 193
  • 38.6
  • 33 segs/9 lymphs/2 monos/55 eos
  • Chem panel WNL
  • ESR 62
  • UA WNL
  • EMG mononeuritis multiplex
  • Median n., peroneal n., bilateral tibial n.

8
(No Transcript)
9
Churg-Strauss Syndrome
  • Allergic granulomatosis and angiitis
  • Allergic rhinitis
  • Asthma
  • Eosinophilia
  • Incidence 3 cases/million general population
  • 10 pts with major vasculitis CSS
  • Frequency 2nd to Wegeners
  • Etiology unknown likely autoimmune

10
Churg-Strauss Syndrome
  • Clinical Features
  • 3 phases
  • Prodrome atopy, asthma, allergic rhinitis
  • Eosinophilic phase
  • Vasculitis
  • Asthma gt95
  • Skin involvement 66
  • Neurologic disease 75
  • Cardiovascular 50 of deaths

11
Churg-Strauss Syndrome
  • Diagnosis
  • ACR criteria 4 of 6 85 sensitive, 99.7
    specific
  • Asthma
  • Eosinophilia gt10
  • Mononeuropathy or polyneuropathy
  • Migratory/transient pulmonary opacities
  • Paranasal sinus abnormality
  • Biopsy with vesseleos in extravascular areas

12
Churg-Strauss Syndrome
  • Treatment
  • Corticosteroid therapy x 6-12 weeks
  • Follow eosinophils and ESR
  • pANCA positivity persistence unhelpful
  • Cyclophosphamide, imuran, IVIG
  • Prognosis unclear
  • Most deaths in vasculitic phase
  • Cardiac and GI involvement poor prognosis

13
Leukotriene Receptor Antagonists and CSS
14
Churg-Strauss Syndrome
  • Multi-system disorder characterized by asthma,
    allergic rhinitis, eosinophilia
  • Diagnosis difficult ACR criteria to be used in
    conjunction with clinical judgment
  • Etiology unknown
  • Role of LTA not defined presently
  • Allow oral corticosteroid taper
  • Elicit or promote development of CSS
  • Treatment with corticosteroids
    immunosuppressive agents

15
references
  • Green RL, Vayonis AG. CSS after zafirlukast in
    two patients not receiving systemic steroids.
    Lancet 1999353725-726.
  • Jamaleddine et al. LTA and the Churg-Strauss
    Syndrome. Semin Arthritis Rheum 31218-227.
  • Le Gall C., et al. Inhaled Corticosteroids and
    Churg Strauss Syndrome a report of five cases.
    Eur Respir J 200015978-981.
  • Pedersen K.E., Bochner BS, Undem BJ. Journal of
    Pharmacology and Experimental Therapeutics.
    1997281655-662.

16
references
  • Rothenberg M.D. Eosinophilia. NEJM
    19983381592-1600.
  • Tuggey JM, Hosker HSR. Churg Strauss Syndrome
    associated with montelukast therapy. Thorax
    200055805-806.
  • Weller PF, Plaut M, Taggart V et al. The
    relationship of asthma therapy and Churg Strauss
    syndrome NIH workshop summary report. J
    Allergy clin Immuno 2001108175-83.
  • Weschler ME, garpestad E, Flier SR et al.
    Pulmonary infiltrates, eosinophilia, and
    cardiomyopathy following corticosteroid
    withdrawal in patients with asthma receiving
    zafirlukast. JAMA 1998279455-457.
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