Clinical Problem Solving

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Clinical Problem Solving

• November 11, 2008
• Lisa Willett, MD
• JR Hartig MD

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Baby JR
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Case 1

• 49 year old AAM
• room spinning x 2 days
• Unsteady gait
• Sudden onset
• No hearing loss, no tinnitus
• No recent URI symptoms
• Not positional

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Case 1, continued

• Woke up from sleep with symptoms
• Also had a severe headache
• Constant, but wax/wane, top of head
• No fevers, no mental status changes
• No better after 2 days

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PMH

• Left inner ear surgery 1995
• Mastoidectomy
• Left facial nerve damage
• Hyperlipidemia
• HTN
• CAD MI in 2004
• DM2
• Tobacco abuse

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Medications

• HCTZ
• Actos (Pioglitazone)
• Verapamil
• Vytorin (simvastatin and ezetimibe)

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FH/SH

• Single
• Quit heavy alcohol 6 months ago, now 1-2 beers
  daily
• Tobacco 1 ppd for over 35 years
• No drugs
• Mother DM2, HTN
• Father Died of colon cancer, age 68

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Physical Exam

• 141/85 82 16 98.5
• CN (except 7), motor, sensation, mental status
  normal
• Bilateral nystagmus with right lateral gaze
• Speech normal
• Mild dysmetria finger to nose
• Gait unsteady - stumbling

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Labs

• WBC 13,000
• Hct 45
• Plt 253 k
• Cr 1.2
• Glucose 118
• A1C 8.5

• TC 241
• TG 284
• HDL 42
• LDL 142
• LFTs normal
• Ca 9.6

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Next steps?
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Imaging

• CT head possible cerebellar mass versus stroke
• MRI of brain cerebellar infarct

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Acute Vestibular Syndrome

• Rapid unilateral injury to either peripheral or
  central vestibular structures
• Severe vertigo, nausea and vomiting, spontaneous
  nystagmus and postural instability

NEJM 1998339680-85
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Most Common Causes of Vertigo

• Benign paroxysmal positional vertigo
• Acute vestibular neuronitis
• Menieres disease

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Other Causes of Vertigo

• Drugs
• alcohol, cocaine, barbituates
• antihypertensives, diuretics, nitroglycerin
• antidepressants, sedatives
• salicylates, aminoglycosides, seizure meds
• Cerebrovascular disease (stroke)
• Migraine
• Multiple Sclerosis
• Brain tumor

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Vertigo Peripheral vs. Central

• Peripheral
• Severe
• Sudden onset
• Seconds to minutes
• Positional
• Fatigable

• Central
• Mild
• Gradual
• Weeks to months
• Not positional
• Not fatigable
• Associated neurological deficits

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Cerebellar Infarction

• 25 of acute vestibular syndrome in patients with
  risk factors for stroke
• HTN, DM, smoking, afib, valvular heart disease
• Cerebellar infarct more common than cerebellar
  hemorrhage (85 to 15)
• Male (2-3 times more than female)
• Mean age 65 13 years

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Cerebellar Infarction

• Sudden onset posterior headache
• Severe vertigo
• Nausea, vomiting
• Unsteadiness of gait (ataxic gait trunk)
• A patient able to walk normally is unlikely to
  have a significant cerebellar infarct
• Usually improve in days, gradually resolve over
  weeks

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More severe

• Dysarthria
• Diplopia
• Dysphagia
• Impaired consciousness
• If hemorrhage or swelling, neurosurgical
  evacuation
• Poorer prognosis

Brainstem Infarction
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Neuroimaging

• Neurological signs or symptoms
• Cerebrovascular risk factors
• Progressive unilateral hearing loss
• MRI is test of choice

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Take Home Points

• Be aware of the worrisome features of vertigo
• non-positional, HA, cant walk, risk factors
• Patients with neurological signs or symptoms and
  with cardiovascular risk factors need an MRI

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JR goes to Medical School
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JR or Kasey?
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Case 2

• 62 yowm complains of laryngitis
• Has been hoarse for 3 months
• Coughs up phlegm daily, worse at night
• New symptoms of GERD for which hes taking over
  the counter Tagamet and Tums
• No URI symptoms

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Case 2

• PMH
• Diabetes diagnosed 5 months ago
• HTN
• LBP, s/p surgery 1986
• Medications
• Monopril 40mg daily
• Norvasc 5 mg daily
• Amaryl 2 mg daily

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Case 2

• SH
• Recently divorced
• Quit tobacco in 1980, prior 3 ppd since youth
• Quit alcohol in 1980, prior heavy drinker
• No IV drug use
• FH noncontributory
• ROS negative

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Case 2

• Physical exam
• Afebrile, 114/80 76 wt 207 lbs
• Heent normal
• Lungs clear
• CV normal
• No lymphadenopathy
• Voice is scratchy

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Case 2

• Labs unremarkable
• CXR normal
• Started empirically on PPI
• And referred to ENT for laryngoscopy

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Case 2

• Reddish thickened right true vocal cord
• Polypoid enlargement at anterior 1/3, preventing
  clear contact of vocal cords
• No obvious ulceration or infiltrative mass

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Case 2

• Biopsy Invasive squamous cell carcinoma,
  moderately differentiated

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Hoarseness

• Caused by interference with normal apposition of
  the vocal cords
• Inflammatory, traumatic, and neoplastic
• Most often from viral URI or voice abuse
• gt2 weeks must be evaluated

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Causes of Chronic Hoarseness

• Chronic irritants (inhaled chemicals, smoking,
  alcohol)
• Chronic GERD
• Chronic sinusitis with postnasal drip
• Chronic vocal strain
• Vocal cord lesions polyps, nodules, leukoplakia
• Vocal cord paralysis
• Systemic hypothyroidism, RA, virilization

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Causes of Chronic Hoarseness

• Laryngeal carcinoma
• Squamous cell carcinoma
• Risk factors smoking and alcohol
• From mucosal surface of larynx
• Metastasizes regionally to cervical nodes
• Hoarseness early if vocal cords involved
• Pain late from ulceration, especially with
  swallowing

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JR comes to UAB
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Case 3

• 25 yowf with boils on legs
• Bilateral, anterior below knee
• Red bumps
• Painful
• Almost 6 weeks
• Went to doc-in-box, was given a shot and
  antibiotics
• No better

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Case 2, continued

• PMH none
• Meds none
• SH married, monogamous, no children
• No alcohol, tobacco, drugs
• FH non-contributory
• ROS no fever, no chills, no weight loss

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PE

• Afebrile VSS
• Bilateral erythematous, subcutaneous nodules
  anteriorly
• Right leg 0.4 cm ill defined, non tender
  swelling
• Left 1.5 cm firm, tender, ulcerated

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Next steps?

• Labs unremarkable
• Bactrim no better

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Numerous clumped acid-fast bacilli, cultures
Mycobacterium chelonae
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Course

• From sensitivities, 8 wks cipro clarithromycin
  ? better
• At 10 weeks, right nodule worse
• ID, then extensive debridement of necrotic
  tissue down to anterior compartment muscle fascia
• Follicular abscesses, suppurative granulomas,
  sinus tracts
• 6 months clarithromycin, cipro, Bactrim

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Additional History Obtained

• Pedicure treatment at same salon once a month for
  3 months
• Lesion within 1 week of last appointment
• Salon had all 4 whirlpool footbaths contaminated
  with RGM
• M chelonae
• M fortuitum

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Pedicures

• Americans spend over 6 billion per year in nail
  salons
• Rapidly growing mycobacterial (RGM) infection
  outbreaks
• Leg shaving increases risk
• Lesions below knee
• 100 customers in a California salon

NEJM 20023461366-71
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Primary Cutaneous RGM Lesions

• Result from minor trauma
• Nonsterile injections
• Contaminated surgical instruments
• Diagnosis missed due to variable presentations
• Time course weeks - months after exposure

Arch Dermatol 2003139629-34
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RGM infections

• Primary cutaneous
• Cellulitis
• Furunculosis
• Ulcers
• Painful nodules
• Sinus tracts

• Extracutaneous
• Meningitis
• Keratitis
• Osteomyelitis
• Endocarditis
• Bacteremia

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Rapidly Growing Mycobacteria

• M fortuitum and M chelonae
• Ubiquitous in soil and water
• Rapid growth after 3 to 7 days on media
• Usually requires multi-drug therapy for months,
  based on resistance patterns
• Amikacin, imipenem, quinolones, sufonamides
  usually susceptible
• Doxycycline, clarithromycin, cefoxitin variable

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Take Home Points

• Consider RGM infection
• Recent pedicures with recurrent lower extremity
  furunculosis and abscesses unresponsive to
  conventional antibiotic therapy
• Biopsy to guide antibiotic selection

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