Clinical Problem Solving 82807

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Clinical Problem Solving8-28-07

• Moderator Stuart Cohen, MD
• Discussant Mark Stafford, MD

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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

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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

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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

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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

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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

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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

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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

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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

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Classification Criteria for Adult Stills disease
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Clinical Manifestations of Adult Stills disease

• Fever
• Evanescent rash
• Arthritis/Arthralgias
• Severe mylagias
• Lymphadenopathy
• Splenomegaly
• Acute pharyngitis
• Hepatic dysfunction
• Pleuritis
• Pericarditis
• Mild alopecia

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Laboratory Values in Adult Stills Disease
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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.

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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

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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

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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

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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

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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

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Case 2

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

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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

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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

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Case 2

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

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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

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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)

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Physical Findings

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

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Associated Risk Factors

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

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Papilledema
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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

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Pseudotumor Cerebri Treatment

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

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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

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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

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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

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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

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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

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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

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Scrotal Anatomy
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Testicular Torsion
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Torsion of Appendix Testis
Blue Dot Sign
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Distinguishing Characteristics of Acute Scrotal
Pain
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• Hydrocele Varicocele

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The End