CPS vs CMRs

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CPS vs CMRs

• Discussants
• Lindsey Roenigk
• Heather Shah
• Elizabeth Turnipseed
• Michael Burch

Presenters Lisa Willett Stanford
Massie J.R. Hartig
GIM Noon Conference May 15, 2007
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Case 1

• 45 YOAAF, with multiple medical problems
• my finger hurts
• Left 5th digit
• 2-3 days
• Red and swollen
• No trauma or injury
• No fever or chills

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PMH

• 6 weeks prior, right ankle infection
• Dx cellulitis and pyarthrosis
• Hospitalized
• Operative ID
• Negative cultures
• Discharged home on Keflex
• Complete resolution of symptoms

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Other PMH

• ESRD, h/o PD, now s/p cadaveric renal transplant
  2002
• DM2
• HTN
• Hyperlipidemia
• GERD
• Hyperparathyroidism

• Prednisone 7.5 qday
• Cyclosporin 125 BID
• CellCept 1000 BID
• Lasix 80 BID
• Clonidine 0.1 BID
• Atenolol 50 qday
• Zocor 40 qHs
• Insulin 70/30

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SH

• Married, no alcohol, tobacco or drugs
• Mother died of MI
• Many family with DM and ESRD
• ROS negative

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Physical Exam

• T 98.9 121/77 73
• Non toxic, unremarkable except left hand
• Exquisite tenderness to palpation of MCP
• Mild tenderness of PIP
• Swelling, mild erythema, no warmth
• Limited ROM because of pain
• Wrist, ankle, other joints WNL

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Labs

• WBC 9.4, normal diff
• Cr 1.6
• Xray swelling of finger and dorsum of hand, no
  fracture, no osteomyelitis

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Now what??

• Rheumatology consult for aspiration

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Gout

• Inflammatory arthritis triggered by
  crystallization of uric acid
• Purine metabolism -gt urate
• Only humans can develop gout
• Lack uricase enzyme
• Extensive reabsorption of filtered urate
• Associated with insulin resistance, HTN,
  nephropathy and disorders of increased cell
  turnover

Annals, 143(7)2005
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Overview of the pathogenesis of gout
Alcohol
Choi, H. K. et. al. Ann Intern Med
2005143499-516
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Renal Transplant and Gout

• Gout prevalence up to 15
• Hyperuricemia even more common
• Several factors
• Diurectics used for edema and HTN
• Poor graft function impairs renal uric acid
  excretion
• CYCLOSPORIN
• Impairs renal excretion, at renal tubules
• Increased reabsorption

J Am Soc Nephrol 11974-792000
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Renal Transplant and Gout

• Within months to years after transplant
• Behaves similarly to gout in other settings
• Maintenance immunosuppression does not mitigate
  symptoms
• Similar location MTP, wrist, knee, elbow
• Hip, shoulder, SI joint
• Enthesitis and tenosynovitis
• Tophi may be more common (cyclosporin promotes
  uric acid retention)

J Am Soc Nephrol 11974-792000
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Treatment

• Extreme caution with NSAIDS
• Colchine for most
• Myoneuropathy
• Corticosteroids
• 0.5 to 1 mg/kg per day for 3 to 7 days, then
  tapered to their maintenance within 14 days
• Stop cyclosporine as last resort (transplant
  physicians call, not yours)
• Prophylaxis colchicine daily or allopurinol

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Case 2

• 68 y.o. AA male with mild fatigue and chronic
  anemia
• Anemia dates back to 2001 at least
• Workup at the time suggested ACD
• Baseline Hgb 11.7 to 12.8, normochromic and
  normocytic, normal B12 and Folate, Reticulocyte
  count 0.8
• Other than chronic joint pains from arthritis,
  he denies other complaints

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Case 2

• PMH
• Pagets disease of the bone (dx 1980s)
• Total Knee Replacement due to OA
• Right shoulder surgery (remote--injury)
• Bilateral Carpal Tunnel
• Medications Vioxx, Tylenol PRN

Case presented in 2004
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Case 2

• SH retired Negro league pro baseball player, no
  T/E/D. Never married.
• FH Noncontributory
• ROS
• Chronic daily pains in joints of knees, hips,
  shoulders relieved with Tylenol
• No significant morning stiffness
• Refused surgery for CTS 2003

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Case 2

• Physical Exam
• Vital Signs Weight 167, Height 6 2
• General Tall, thin NAD
• HEENT no adenopathy
• Abdomen no hepatosplenomegaly
• MS no signs of inflammation
• Rest of exam unremarkable

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Case 2

• Labs
• Hct 36 (WBC and PLTs normal)
• MCV 86, RDW14, Retic 0.8
• ESR 35, ANA 180, RF negative
• Ferritin 175, PSA and TFTs normal, AP 199 (near
  baseline)
• SPEP/UPEP negative
• Serum/Urine IFE abnormal
• IgA lambda in serum, kappa light chain in urine

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Case 2

• Skeletal survey (-)--Pagets in shoulder
• Patient referred to hematology
• Hematology felt that immunoglobin studies were
  unlikely to suggest real pathology
• Checked Testosterone
• Level returned at 28 (260-1000)

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Case 2

• Patient started on testosterone replacement shots
• Joint aches and fatigue improved, as did his
  anemia
• Dx Hygonadism induced anemia of chronic disease

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Anemia of Chronic Disease

• Mild anemia, normocytic, normochromic
• Reduction in RBC production (BM)
• Key features
• Iron trapping in macrophages
• Insufficient response by BM to anemia
• Relatively lower EPO production
• Hallmark Normal sat, low TIBC
• Hepcidin acute phase protein

UpToDate. Online Version 15.1
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Low Testosterone Levels and the Risk of Anemia in
Older Men and Women
Prevalence of anemia
Arch Intern Med. 20061661380-1388
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Case 2 Its not over yet.

• Patient noted visual complaints at routine visit
  with ophthalmologist
• Found to have visual field defects
• MRI confirmed pituitary macroadenoma (3x2x3)
• Evaluation of hormonal axes revealed all normal
  except testosterone and prolactin (slightly
  elevated)
• Patient refused surgery and has been stable

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Anemia, testosterone, and pituitary adenoma in men

• Retrospective review pituitary adenomas
  requiring surgery (197 patients)
• 46 of men with low serum concentrations of
  testosterone were anemic.
• In men with low testosterone, average Hct 39.9,
  (45.6 for men with normal testosterone).
• Men with macroadenomas most likely to have both
  anemia and low testosterone levels.
• Patients with anemia 84 men and 16 women

J Neurosurg 98974977, 2003.
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Monitoring of testosterone replacement

• Assess for desirable effects
• Assess for undesirable effects
• Check levels to confirm response
• Check for complications
• BPH (symptom score)
• Prostate CA PSA/DRE (3 mos, then q12)
• Erythrocytosis (CBC)
• Worsening of OSA

UpToDate. Online Version 15.1
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Evaluation of Low Testosterone

• Repeat the value
• Check FSH/LH to identify source (1or 2)
• Consider evaluating other pituitary functions
• MRI is indicated if
• VF defects or neurologic impairment
• FSH/LH levels low (or not elevated)
• Other pituitary dysfunction evident
• Some suggest doing if testosterone level very low
  
• lt250 if age 25, lt150 if age 75

UpToDate. Online Version 15.1
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Case 3

• 12 yo W? presents to clinic with abdominal pain
  and asks you not to tell her mother

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Case 3.2
www.thachers.org/dermatology.htm
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The Real Case 3

• 29 yo W? presents to clinic with a 5 days of
  otalgia
• Right ear only. Denies F/C
• Admits to URI symptoms, ill child (23mo) with
  cold, and a popping sensation in ear
• No ST, N/V/D
• No exposures, trauma, foreign bodies (Q-tips)

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Additional History

• PMH
• Frequent OM as child
• Frequent URI since children (G3P3 23mo-6yo)
• Ø Meds, NKDA
• SH married, part-time daycare worker, smokes
  (outside the home)
• FH no major illnesses
• ROS no swimming

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Physical Exam

• VS 99.0 P 76 R 16 BP 114/72
• Gen WDWN NAD
• Eyes no discharge or erythema
• OP mild erythema, no exudate, midline structures
• CV/Resp RRR, CTA B
• Ears

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Possible Exams
UpToDate. Online Version 15.1 www.aafp.org
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Actual Exam
www.fpnotebook.com
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What Next?

• Labs
• Testing
• Treatment

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Common Clinical Problems
www.kennelandhomesecurity.co.uk
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Not the Rare Breeds
wuarchive.wustl.edu
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Unfortunately

• 3 days later the patient returns to clinic
• She didnt fill the prescription
• She now complains of severe pain behind the R
  ear, fever, and mild nausea.

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Physical Exam

• VS 102.2 P 98 R 20 BP 116/82
• Large amount of erythema and swelling noted
  posterior to the ear
• Unable to visualize the TM
• Remainder of the exam is unchanged

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Appearance Now
www.emedicine.com
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What Now?
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Otitis Media in Adults

• Not a common Internal Medicine problem but is
  a VERY common problem
• Disease of the young
• Same organisms and pathophysiology
• Same treatment regimens
• Very little evidence for adults

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Risk Factors

• Age
• Daycare
• Exposure to tobacco smoke
• Allergic Rhinitis
• Anatomic abnormalities
• Cystic Fibrosis and others

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Bacteriology
UpToDate. Online Version 15.1
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Symptoms

• Otalgia
• Hearing Loss
• Fever
• URI
• Nausea/Vomiting
• Otorrhea

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Signs

• Erythema
• Effusion
• Lack of mobility of TM
• Abnormal tympanometry
• Usually no pain with palpation or manipulation of
  ear

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Exam Reminder
www.healthofchildren.com
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Tympanograms
UpToDate. Online Version 15.1
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Definition
UpToDate. Online Version 15.1
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Treatment

• Pain
• Systemic Agents
• NSAIDs, ASA, Tylenol
• Topical Agents
• Antipyrine/Benzocaine/Glycerin (Auralgan)
• Herbal extract (Otikon)
• Things that probably do not work
• Decongestants
• Warm/Cold compress, oil, cotton

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Treatment

• Antibiotics or Not?
• Choice of Agent
• Amoxicillin
• Amoxicillin/clavulanate
• Cephalosporins
• Macrolides
• Duration of Therapy

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Follow-up

• Resolution of effusion
• Hearing
• Persistent symptoms
• Ruptured TM

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Take Home Points

• Become proficient at TM exams
• Dont forget to treat the pain
• Amoxicillin will likely still do the job!

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Thanks and good luck!!
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