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Clinical Problem Solving 82807

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... throat, fevers (103), rash on chest and back and bilateral knee and ankle pain ... Synovitis in Bilateral wrists, knees, ankles ... – PowerPoint PPT presentation

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Title: Clinical Problem Solving 82807


1
Clinical Problem Solving8-28-07
  • Moderator Stuart Cohen, MD
  • Discussant Mark Stafford, MD

2
Case 1
  • 53 y/o WM presents with 3 week history of joint
    pain, rash and fevers
  • 3 weeks PTA fever and sore throat
  • Received IM antibiotic
  • 2 1/2 weeks PTA admitted OSH with sore throat,
    fevers (103), rash on chest and back and
    bilateral knee and ankle pain
  • Reports tick exposure 2 months PTA
  • Empiric Rx for Lyme disease with Rocephin,
    doxycycline and prednisone
  • Symptoms improved while in hospital- D/C home on
    medrol dose pack and doxycycline

3
Case 1
  • 1 week PTA, the fever returns with rash on
    chest, back and upper extremities and worsening
    knee, ankle, elbow, wrist and hand pain
  • TTE- normal study
  • CT abdomen/pelvis- Normal study
  • Re-treated with Rocephin, Doxy and steroids
  • Describes myalgias associated with fever spikes
  • No headache, vision changes, photosensitivity or
    oral ulcerations
  • No abdominal pain, nausea, vomiting or blood per
    rectum
  • No cough, hemoptysis, chest pain or shortness of
    breath

4
Case 1
  • Pmhx
  • T2DM, DJD
  • Meds
  • Glucatrol, ultram, doxy, medrol dosepack
  • Sochx
  • Works as a boilermaker
  • Previously worked in logging industry
  • 1 ppd tob x 30 yrs
  • No significant ETOH, No IVDA

5
Case 1 Physical Exam
  • Temp 101, 124/68, 75, 96O2 sat
  • Skin non-confluent erythematous macular rash
    over chest and back
  • HEENT PERRLA, EOMI, Oropharynx clear without
    exudate. No cervical adenopathy. Sclera anicteric
  • Lungs CTA
  • Cardiac RRR. No murmurs or rubs. No S3
  • Abd S/NT/ND/ BS. No HSM

6
Case 1 Physical Exam
  • M/S
  • Synovitis in Bilateral wrists, knees, ankles
  • Bilateral second MCP and bilateral second and
    third PIP joint synovitis
  • No significant enthesitis or peri-arthritis
  • Neuro
  • CN 2-12 intact
  • motor and sensory exam- Normal

7
Case 1Diagnostic Studies
  • Sodium 132, potassium 5.2, BUN15, Cr 0.9, glucose
    150
  • WBC 21.6 (95 segs, 4 lymph, 1 mono), HCT 34,
    PLTS 236
  • AST 49. ALT 56, Alk phos 85, T bili 0.8, Albumin
    2.5
  • Uric acid 7.0, CPK 75
  • Hepatitis B and C serologies Negative
  • EBV IgG, IgM Negative
  • Parvo IgM Negative
  • Typhus IgG, IgM Negative
  • HIV Negative
  • ASO Negative

8
Case 1
  • ESR 40, CRP 15.3
  • ANA- negative
  • RF- negative
  • C and P- ANCA Negative
  • Ferritin 9600
  • TEE- no vegetations
  • Chest CT- normal study

9
Adult Stills Disease (ASD)
  • First described in children by George Still in
    1896
  • "Still's disease" became the eponymous term for
    juvenile rheumatoid arthritis
  • The etiology of ASD is unknown- although a
    variety of infectious triggers have been suggested

10
Classification Criteria for Adult Stills disease
11
Clinical Manifestations of Adult Stills disease
  • Fever
  • Evanescent rash
  • Arthritis/Arthralgias
  • Severe mylagias
  • Lymphadenopathy
  • Splenomegaly
  • Acute pharyngitis
  • Hepatic dysfunction
  • Pleuritis
  • Pericarditis
  • Mild alopecia

12
Laboratory Values in Adult Stills Disease
13
Clinical Course
  • A self-limited or monophasic pattern usually
    lasting less than one year, with complete
    resolution of symptoms.
  • A polycyclic or intermittent course in which
    there are one or more flares of disease with
    complete remission between episodes.
  • A chronic course characterized by persistently
    active disease, usually due to a chronic,
    destructive arthritis.

14
Treatment
  • NSAIDs (including high dose ASA) first line
    therapy
  • Glucocorticoids (0.5-1.0 mg/kg/day)
  • Used for pts with high fevers, debilitating joint
    pain and/or internal organ involvement
  • DMARDs (Methotrexate)
  • Used in patients with chronic course as steroid
    sparing agent

15
Case 2
  • 29 yo WF (married physician) presents w/
  • 1 month h/o daily headaches of moderate severity
  • pain is bilateral, posterior occipital and
    behind her eyes
  • Frequently present upon waking and persists
    throughout the day
  • Describes occasional blurry vision lasting about
    a minute

16
Case 2
  • Denies associated nausea or vomiting
  • No fevers, chills or night sweats
  • No hearing loss, vertigo or lightheadedness
  • Denies weakness or sensory deficits
  • mild sinus congestion but denies rhinorrhea or
    nasal drip
  • Describes pulsatile tinnitus for past several
    months

17
Case 2
  • PMhx None
  • Meds minocycline, loratidine
  • FH Non-contributory
  • SH resident at UAB
  • No ETOH, tob or drugs
  • Married, no kids
  • no recent travel

18
Case 2
  • Physical Exam
  • Uncomfortable appearing, A O x 3
  • 98.9, 78, 128/42, 14, 99 RA, 54, 198 lbs.
  • Heent
  • PERRLA, EOMI,
  • OP without exudate
  • No frontal or maxillary sinus tenderness
  • No nuchal rigidity

19
Case 2
  • Neuro Exam
  • CNs 2-12 intact
  • Discs poorly visualized
  • Normal Motor and Sensory Exam
  • Normal gait, normal tone and reflexes

20
Case 2
  • DATA
  • Basic Metabolic Panel Normal
  • LFTs - Normal
  • WBC 3.3 (54 segs, 32 lymphs, 10 monos)
  • HCT 40, MCV 88, plt 15
  • Urine HCG NEG
  • UA 1 ketones

21
Case 2
  • CT Brain (non-contrast)
  • No mass lesion, no bleed
  • Normal study
  • Optho exam
  • Blurring of optic cup with edema surrounding
    optic disc
  • MRI with venography
  • No intracranial mass lesion, No meningeal
    infiltrative or inflammatory process, no dural
    venous thrombosis

22
Case 2
  • Lumbar puncture (lateral decubitus position)
  • Opening pressure 40 cm H20 (normal lt 25)
  • Normal cell count and diff
  • Normal protein

23
Pseudotumor Cerebri(Idiopathic Intracranial
Hypertension)
  • Unknown etiology
  • Primarily affects obese woman of childbearing age
  • Pathophysiology
  • Likely secondary to increased resistance to CSF
    outflow at the arachnoid granulations

24
Typical Symptoms of Pseudotumor Ceebri
  • headache (94)
  • transient visual obscurations or blurring (68)
  • pulse synchronous tinnitus or "wooshing noise" in
    the ear (58)
  • pain behind the eye (44)
  • Diploplia (38)
  • visual loss (30)
  • pain with eye movement (22)

25
Physical Findings
  • Papilledema
  • Visual field defects
  • Decreased visual acuity
  • Limited abduction of one or both eyes
  • (false-localizing sixth cranial nerve palsy)

26
Associated Risk Factors
  • Female of reproductive age
  • Obesity
  • Recent weight gain
  • Drugs
  • Minocycline, Accutane, cimetidine,
    corticosteroids, levothyroxine, cyclosporine
  • Hypothyroidism
  • SLE
  • Adrenal Insufficiency

27
Papilledema
28
Diagnosis
  • Modified Dandy Criteria
  • 1) Signs symptoms of increased ICP CSF
    pressure gt25 cmH2O
  • 2) No localizing signs with the exception of
    abducens nerve palsy
  • 3) Normal CSF composition
  • 4) Normal to small ventricles on imaging (MRI
    recommended) with no intracranial mass

29
Pseudotumor Cerebri Treatment
  • Treat underlying condition
  • Weight loss
  • Withdrawal of offending drug
  • Diuretics
  • Acetazolamide (reduces CSF production by 50)
  • Corticosteroids
  • Repeat Lumbar punctures

30
Case 3
  • 47 y/o male presents with 1 day history of left
    sided scrotal pain
  • Worked in yard 2 days prior to presentaion
  • Denies recent trauma
  • No dysuria, frequency or urgency
  • Denies penile discharge
  • No nausea, vomiting or abdominal pain
  • No fevers, chills or night sweats

31
Case 3
  • PMH
  • HTN, T2DM, DJD
  • Right inguinal hernia repair (age 27)
  • MEDS
  • Metformin, HCTZ, ASA, Acetaminophen
  • Sochx
  • Works as truck driver
  • Married with 2 kids
  • Smokes 1ppd, social ETOH, denies IVDA
  • Famhx
  • Non-contributory

32
Case 3
  • PE
  • 165/78, 80, 14, 98.7,
  • Obvious pain but NAD
  • Circumcised, no penile lesions or discharge
  • Significant scrotal swelling with erythema
  • Focal area of pain on superior aspect of testis
  • No detectable inguinal hernia
  • Prostate non-tender, not enlarged

33
Case 3
  • PE
  • cremasteric reflex intact
  • Pain not improved with elevation of scrotum
  • No blue-dot sign
  • Labs
  • WBC 10K, normal differential
  • HCT 45, Platelets 243
  • Chem 7 WNL
  • UA trace protein, 0 WBC, 0 RBC

34
Case 3
  • Further Evaluation
  • Scrotal Doppler Ultrasound
  • detectable doppler signal suggesting normal
    testicular blood flow
  • Large hydrocele
  • lesion of low echogenicity with a central
    hypoechogenic area ?
  • Torsed Appendix Testis

35
Differential Diagnosis of Scrotal Pain
  • Acute
  • Testicular torsion
  • Torsion of Appendix Testis
  • Epididymitis
  • Inguinal hernia
  • Trauma
  • Mumps
  • Fourniers gangrene
  • Nonacute
  • Varicocele
  • Epidermal cyst and spermatocele
  • Hydrocele
  • Testicular cancer

36
Scrotal Anatomy
37
Testicular Torsion
38
Torsion of Appendix Testis
Blue Dot Sign
39
Distinguishing Characteristics of Acute Scrotal
Pain
40
  • Hydrocele Varicocele

41
The End
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