Monday, December 17, 2012

The Sleeping Patient

An elderly patient has been admitted to the hospital about three weeks ago. His presentation was remarkable for profuse watery diarrhea and terrible abdominal pain. Diagnosed promptly with C diff he was started on vancomycin PO. Because of worsening abdominal pain, leukocytosis Flagyl IV was added. Patient developed perforated bowel and underwent surgery for hemicolectomy.

Our story begins one week after surgery. The sepsis has resolved, but there is one big issue. He does not wake up. NG delivers feed solution. There is a small mask that fits over the patient's tracheostomy site.

There is minimal spontaneous activity. No nystagmus. Corneal reflex present. He seems to feel pain to prick, however the reaction is minimal. Sensation is intact bilaterally. The neck is supple. There are no rashes.

The medication list does not include any sedative/psychotropic medication.

Brain MRI unremarkable. No evidence of infection. Electrolytes, ABG are WNL. No evidence of infection.

He is about to be referred to palliative/comfort care. 

When I think about the causes of acute encephalopathy, I divide them primarily in things in the brain and things outside the brain. Things in the brain would be stroke, masses, seizures, local autoimmune conditions (lupus, paraneoplastic etc). Outside the brain would be everything else metabolic, infectious, endocrine, autoimmune etc. See I VINDICATE (AIDS)

Reviewed all the workup and there was only one missing lab. Next morning the lab reported that the cortisol was 0.5 (normal 6-10 our laboratory). With emotion I ordered another AM cortisol level the next day along with ACTH and high dose cosyntropin stimulation test. Great there was a lead. The second cortisol was 1 and the stimulation failed to lift it more than 6.

Hydrocortisone IV was initiated at 50 mg q8h. The next morning patient awake, able to recognize his wife. Two days later, I found him sitting in bed reading the newspaper. The hydrocortisone was tapered to physiologic levels.

It is very likely that the hypotension / sepsis affected the adrenal glands and the patient had encephalopathy due to profound adrenal insufficiency.

Sunday, September 2, 2012

The stubborn ileus

Almost a year ago, during my last rotation as a resident I had to do another month of night-shift. How wonderful is to work nights! Fortunately you can always find a cool case. And I found one.

Just finished admitting a young man who took too many shroom  and I got a call regarding an existing patient. An 18 yo W, the nurse told me, with severe constipation and abdominal pain needs more Miralax. That was a bit weird, so I asked few more questions. The patient had no past medical history. Already had a CT of the abdomen (equivalent dose of radiation of 300-500 chest xrays) that showed nothing abnormal. Labs unremarkable (lytes, pregnancy screening test). She had been diagnoses with ileus and started on industrial doses of laxatives. An enema proved unsuccessful.

Before I give her more Miralax, I decided to interview and examine the patient. I found her in bed, laying in fetal position. Well, it started about a week ago, with diffuse abdominal pain, followed by constipation, followed by inability to pass flatus. Then I turn on the examination lights (during my internship I did not want to bother a patient by turning the bright lights on and...missed something big). Started the exam by looking at her hands (cool internists always examine the nails, palms etc), followed by the rest of the body. Her legs had some purple non blanching petechiae.

 Non blanching petechiae could be vasculitis. And abdominal pain with vasculitis in a young patient are very likely Henoch-Schonlein purpura. Her UA had microscopic hematuria, platelets and WBCs were normal. So probably not HUS, ITP, leukemia. Well, it seems that in some cases, H-S syndrome can manifest with ileus.

I scribbled a brief note in the chart (that I don't plan to give more Miralax to treat H-S induced ileus) and left. Two specialists and three days later, the young lady is diagnosed with H-S purpura and started on a brief course of steroids. Her bowel function returns magically.

Wednesday, August 15, 2012

One plus One equal (a complex) One

One morning about two months ago, I was reviewing my rounding list. Among the new patients there was a 62 yo W transferred from a regional hospital for possible stroke. It seemed another bread and butter case.

By the time I arrived in her room, the patient has been seen by the neurologist. He made the diagnosis - peripheral Bell's palsy (asymmetric smile, weak ipislateral forehead, but controlateral forehead was not weak). Indeed, the only obvious focal weakness was in her face.  So, I agreed with the neurologist and before concluding the encounter decided to ask the question that created me a lot of trouble in the past, What else is going on?

Well, she says, I have been diagnosed with uveitis. Uveitis and I are not were well accustomed. I am just an internist, so I have no plan to challenge the ophthalmologist's diagnosis, however at this point I think I can tell the ophthalmologist the etiology of the (anterior) uveitis. The next step sealed the diagnosis in my mind.

The excitement was running so high, without explaining the patient what I was going to do, I went for her neck. It did not take me too long to find plenty of enlarged cervical lymph nodes. Even the parotid gland was swollen. Then I excused for a minute and ran at the PACS station to take a another look at the MRI. Fortunately, the imaging was extended down to upper mediastinum. It had plenty of enlarged lymph nodes.

Heerfordt-Waldenstrom syndrome (facial nerve palsy, uveitis, parotid enlargement and fever) is one of the manifestations of sarcoidosis. She was referred to surgery for biopsy. Somehow the surgeon did not consider this case a priority and she had to stay in the hospital three more days. The ACE level came back before the biopsy was done. It was elevated 1.5 times the upper limit. At this point in time, I get my deserved free days.

The next day she started complaining of bilateral leg weakness. An MRI showed conus medullaris syndrome. Once the biopsy comes back with a diagnosis of sarcoidosis, she was started on steroids and two days later she felt much better.

It seems that she had neurosarcoidosis.

Tuesday, August 14, 2012

Sex, headache and hypertension

A 45 yo M present to ER c/o elevated BP. His BP at home was 180/100 mmHg for many weeks. He has had a chronic HA for many years, however a week ago he developed a different type of headache. It starts in the occipital area and goes in waves towards the vertex. It seems to be worse at night. He started loosing more hair, despite applying the same amount of testosterone gel daily.  And here is the piece of information that reinforced to me this was the real deal: 'Doctor, I am gay'.

He was describing the classical headache for neurosyphilis. RPR was 1:128. Spinal tap showed 50 lymphs. His free testosterone was normal, so probably the alopecia was secondary to syphilis, although it was not the typical alopecia areata.

It was very likely that he had secondary HTN. K was low despite not taking K wasting diuretics, so initially I thought it might be hyperaldosteronism. However decided to take a shot-gun approach. Serum metanephrines, are a good screening test for pheochromocytoma. Norepinephrine was elevated, and confirmed by 24-h urine collection. The rest of the tests, including cortisol, TSH, aldosterone, renal artery Doppler were negative. The only few studies I found, show no relationship between syphilis and hypertension.

The patient was referred to ID for treatment of latent syphilis/neurosyphilis and to endocrinology for treatment of pheochromocytoma (probably isolated, not part of MEN syndrome).

Read more: Syphilitic headache