Interactive Case Presentation

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Interactive Case Presentation

• Doug Kutz MD

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Past Medical History 58 yo male Adult onset DM
on Insulin for 18 yrs. Last HBA1C 10.2, Mild
proteinuria and CRI (30/1.7), Macrovascular
disease HTN w/ dias dysfunction COPD FEV11.0
liter/FVC2.1 liter (little response to
B-agonists) ASCVD Heart Cath 03 Occluded RCA,
L with 40 distal Dz, EF 45 Paroxysmal AFIB
Clopridogel instead of coumadin due to pt.
pref Multiple CVAs (L cerebellar, R pontine, L
caudate) Prostate CA s/p prostatectomy age
49 Dyslipidemia 80 pack year Tobacco Abuse
(Ongoing) Depression/PTSD intolerant of
anything but MAOI Rx and Clonazepam Mononucleolis
with hepatitis while serving in Vietnam
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Medications
Albuterol 2.5mg unit dose via nebulizer
QID Clopidogrel 75mg QD Clonazepam 1mg
TID Furosemide 120mg po BID NPH and Lispro
Insulin Metoprolol 25mg po bid Pantorazole 40mg
QD Spironolactone 25mg QD KCL 40meq po
BID Prednisone 10mg po QD Phenelzine 30mg po BID
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Family History Mother died age 45 of Uterine
CA Father died age 76 sudden death Brother died
67 lung CA and COPD 3 Healthy children ages 24 -
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Admission 12/04

• CC Lightheaded and weak
• HPI Progressive nausea, some emesis, weakness,
  and chills. Not using his insulin or taking his
  meds for 5 days
• Exam
• Vitals Afeb, 148/82 supine, 108 irreg, 22, P.O.
  96 (ra)
• HEENT anicteric slcera, dry mm, neck thick no
  obvious jvd
• Lungs diffusely diminished breath sounds
• CV distant, irreg irreg, no murmur, no rubs
• Abdm soft, nontender, nabs
• Ext trace edema both ankles
• Skin no jaundice or rashes
• CNS nonfocal but slightly confused

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Labs 12/04

• WBC 15.2k, H/H 9.0/26.9, Plt 293k
• Bun/cr 2.9/63 Nml lytes
• Glucose 390, Slight pos serum ketones
• Ast 6098, Alt 1601, Alb 2.8, Alk 386, Bili 0.9,
  Nh3 51
• Coags nml
• Troponin I 1.94
• ECG AFIB w/RVR, LVH, nonspecific ST

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Imaging/Other Studies 12/04

• CT chest COPD and pericardial effusion
• U/S Abdm nml liver and GB, no masses
• Echocardiogram Large pericardial effusion
  without tamponade, LVH with diastolic relaxation
  abnormality

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RN He is becoming hypotensive
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Drug Interactions Phenelzine

• 5-HT agonists
• Buproprion, SSRI, mirtazapine
• Alpha 2 agonists
• Decongestants
• Dextromethorphan
• Ginseng
• Hydralazine
• Most sedatives

• Linezolid (14 days)
• Licorice
• Metoclopramide
• Promethazine
• SAMe
• Sulfonylurea
• Sympathomimetics
• Trazodone

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Hospital Course

• Aggressively rehydrated
• Oliguria and Azotemia resolved after 3 days
• Liver function normalized over 3-4 days
• Hepatitis serology negative
• AFIB did not recur, not a candidate for
  anticoagulation

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Discharge Diagnoses

• Severe dehydration due to severe
  hyperglycemia/medication noncompliance and
  possible viral GE
• Acute Tubular Necrosis
• Ischemic Hepatitis
• Cardiac Enzyme Leak
• Pericardial Effusion, Incidental/? viral
• Paroxysmal AFIB

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Heart disease and Hepatic dysfunction

• Hepatic congestion
• Typically due to exacerbation of chronic CHF
• Liver enlarged and firm on exam
• Modest elevations in ALT, AST, LDH, GGT and
  sometimes alk phos, total bili, and slight
  decrease in albumin
• Mild transient jaundice can occur
• Chronic congestion can lead to cardiac
  cirrhosis with fibrosis of liver on biopsy

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• Cardiogenic Ischemic Hepatitis
• More acute and severe fall in cardiac output
  (such as with an acute MI or Severe CHF)
• Enzyme levels often gt10x normal
• Coagulopathy and Functional renal impairment can
  be associated
• No specific marker for Dx, but typically the
  transaminases drop gt50 in first 72hrs of onset

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Outpatient Visit 3/05

• Dyspnea and pallor, cough.Considering Hospice
• Exam
• Vitals 110/76, 68 reg, Afeb, 22, Wt. up 4 in
  1month, pulse ox 93 on room air
• HEENT dry mm, JVP not visible
• Lungs Diminished diffusely, BS absent in right
  lower ½ w/ dullness
• CV RRR distant, no murmur
• ABDM NABS, NT, Soft
• Ext slight increase edema (now 1)

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Outpatient Labs 3/05

• WBC 9.3k, H/H 10/34.3, Plt 220
• BS 248, Bun/Cr 27/1.3, Nml lytes
• Lfts nml except alk 346
• TSH 1.70
• BNP 467 (nml)
• EKG unchanged

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Outpatient Thoracentesis 3/05

• Red Hazy fluid with many RBCs
• 500 nuc cells (4 seg, 22 lymphs, 74 monos)
• Glucose 238
• LDH 82
• Protein 1.4 (serum 7.7)
• GS Cx neg
• Cytology neg

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Outpatient Imaging 3/05

• Echocardiogram LVH with no wall motion
  abnormalities, nearly resolved pericardial
  effusion.

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Admission 4/4/05

• CCWorsening edema, dyspnea and falls
• HPI
• Despite increasing doses of furosemide, fluid
  build-up in legs has extended up to chest wall,
  now distended and bloated abdomen, weight is up
  30. Positive orthop and PND.
• Dyspnea continues and is now associated with a
  cough. Cough is associated with dizziness and
  lightheadedness. Cough produces yellow sputum 1-2
  tbsp per day.
• Fell yesterday after a coughing spell and hit his
  R orbit now has a black eye.

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Physical Exam 4/05

• Vitals 156/97, 94, 22, 97.8 Wt up 24 from 12/04
  Pulse Ox 90 RA, 94 on 2L NC
• HEENT New circular ecchymosis R orbit, R scleral
  hemorrage, JVP not visible due to habitus and
  edema
• Lungs Absent R base to ½ way up, w/ dullness to
  percussion, BS otherwise diminished diffusely, no
  wheeze
• CV Irr Irr w/no murmur, distant, no gallups or
  rubs
• Abdm Distended with no localized tenderness,
  NABS, prominent liver, no splenomegaly, ?
  Shifting dullness, pitting up to costal margins
• Ext 3 pitting edema bilaterally, pos sacral
  edema

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Initial Laboratory Data 4/05

• Heme Wbc 11.2, H/H 10.3/32.3, Plt 295
• Renal/Lytes Bun/Cr 36/1.3, Gluc 131, Ca 9.2, Na
  141, K 4.8, Mg 2.3
• HepaticAlt/Ast 40/52, AlkP 368, Alb 3.9, Ammonia
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• Coags nml
• Cardiac Enz neg, BNP 2800
• Other D-dimer 3000, U/A 2 prot

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Imaging 4/05

• CXR R effusion, mild PVC
• CT chest No PE, R pleural eff, some obstructive
  changes
• Head CT no change
• U/S abdm normal except ascites
• Echo Nml wall motion, LVH w/ dias dysfunction,
  trace effusion

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Fluid Studies 4/05

• Pleural Fluid almost identical to outpatient
• Ascitic Fluid
• Yellow, clear, moderate rbcs
• 500 nuc cells (20 segs, 15 lymphs, 61 monos)
• Glucose 177
• Amylase 20
• Alb 1.9 (serum 3.9) (sa gradient 2.05)
• GS and Cx neg

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Diuresed 30 JVP now visible to 10cm
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A Diagnostic Study was Obtained

• Doctor I have to get out of here !

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Heart Cath 4/05

• Arterial press 139/86
• LV end-dias pressure 29mmHg (3-12)
• Pulm arterial pressure 51/25 (15-30/4-12)
• Wedge pressure 34 (2-10)
• Kussmauls sign noted on right atrial pressure
  trace, mean pressure RA 26 (2-8)
• Equalization of LV and RV dias press, as well as
  LV and RA dias pressures

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Tissue Diagnosis

• Fibrotic Pericardium, up to 5mm thick.

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Pericarditis

• Can present in 4 ways
• Acute pericarditis
• Incidental effusion
• Tamponade
• Constriction

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Acute Pericarditis

• 85-90 idiopathic, 1-4 viral
• Remainder of cases are post MI, other infx, AAA,
  trauma, neoplastic, post surgical or XRT, uremic,
  connective tissue disease or drug induced
• Classic ECG changes diffuse ST elevation
• Pericardial rub pathognomonic (85 develop)
• Pericardiocentesis indicated for tamponade, or if
  strong suspicion of bacterial infx or neoplasm
• Serologic studies not very helpful (lt10 dx)
• Troponin Leak occurs in 35-50

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Tamponade

• Occurs in 15 idiopathic, but up to 60 with Tb,
  bacterial or neoplastic etiology
• Presents with Becks triad
• Hypotension
• Quiet heart sounds
• Increased Jugular venous pressure
• Can also note compensatory tachycardia and pulsus
  paradoxus (fall in SBP gt10 during insp)

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Constrictive Pericarditis

• Chronic fibrous and/or calcific thickening of the
  pericardium that leads to abnormaly elevated
  diastolic filling pressures
• Most commonly idiopathic after acute or sub acute
  pericarditis (Tb still most common in undeveloped
  countries)
• Post cardiac surgery and radiation therapy
  becoming more common

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Constrictive Pericarditis..

• Clinical findings
• Pulsatile hepatomegaly
• Pericardial knock (early diastole)
• Kussmauls Sign JVP rises (or at least fails to
  fall) during inspiration, due to separation of
  the cardiac pressures from the thoracic pressure
  changes in respiration

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Constrictive Pericarditis..

• Differential Diagnosis
• Other causes of right heart failure
• Restrictive Cardiomyopathy
• PE or Pulm HTN
• Right ventricular infarction
• Mitral stenosis or Tricuspid Disease
• Cirrhosis or Hepatic Vein Thrombosis
• Acute Renal Failure or Nephrotic syndrome
• SVC obstruction or Lymph obstruction
• Myxedema
• Drug Induced (Ca channel, minoxidil, steroids,
  glitazones, NSAIDs,)

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Constrictive Pericarditis..

• Diagnosis
• Unfortunately clinical findings not very specific
• Key echo findings are that of a thickened
  pericardium, a septal bounce, inspiratory
  decrease in pulmonary venous flow, and normal
  relaxation indices.
• MRI is 88 sens, 100 specific using same
  criteria above
• Cath findings that are most specific are
  equalization of RV and LV end dias pressures.
• No widely accepted gold standard

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Constrictive Pericarditis.

• Treatment Pericardectomy
• Use caution with diureses pre-op

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1 month follow up