Clinical Problem @cpsolvers Solving Listen on Zhenya Krapivinsky, - - PowerPoint PPT Presentation

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Clinical Problem @cpsolvers Solving Listen on Zhenya Krapivinsky, - - PowerPoint PPT Presentation

Jun 08, 2023 326 likes •447 views

6/20/2019 The Clinical Problem Solvers A podcast on diagnostic reasoning clinicalproblemsolving.com Clinical Problem @cpsolvers Solving Listen on Zhenya Krapivinsky, MD Department of Medicine & Rabih Geha June 19 th , 2019 History of

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SLIDE 1

6/20/2019 1

A podcast on diagnostic reasoning

The Clinical Problem Solvers

clinicalproblemsolving.com Listen on

@cpsolvers

Department of Medicine

Clinical Problem Solving

Zhenya Krapivinsky, MD & Rabih Geha

June 19th, 2019

Department

  • f Medicine

Chief Complaint

  • CC: Fever & coffee ground emesis

Department

  • f Medicine
  • 61-year-old Cantonese speaking man awoke in

the night with generalized abdominal pain and

  • nausea. Vomited twice with coffee grounds and

called 911.

  • No history of peptic ulcer, cirrhosis, no NSAIDs
  • r blood thinners.
  • 2 month of fevers, sweats, fatigue
  • 6 month of crampy abdominal pain with frequent

formed non-bloody BMs

  • 10lb weight loss

History of Present Illness

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6/20/2019 2

Department of Medicine

Clinical Problem Solving

June 19th, 2019 Stop 1

Department

  • f Medicine

PMH

CAD (CABG 10y ago) HTN HLD Hypothyroidism GERD

Medications

Aspirin Atorvastatin Metoprolol Lisinopril Levothyroxine Omeprazole

NKDA Family History

Father: HTN, DM2

Social History

Postal Officer Moved to Bay Area from China in1987 No recent travel Former smoker (25ppd, quit 15y ago) Drinks ½ glass whisky/day No illicit drug use Divorced Sexually active with girlfriend for the past year Father of 3 children & proud grandfather of 6

Department

  • f Medicine

Physical Exam

BP 92/58 | Pulse 112 | Temp 38.8 C | RR 22 |SpO2 98% GEN: frail looking male, no apparent distress HEENT: dry mucous membranes HEART: regular tachycardia, S4, no m/r/g LUNGS: clear to auscultation bilaterally. no wheezes, rales,

  • r rhonchi

ABD: soft, diffusely tender with greatest pain in the LLQ, hypoactive bowel sounds. DRE: brown stool, guaiac +. EXT: no LE edema, equal pulses NEURO: unremarkable neurological exam

Department of Medicine

Clinical Problem Solving

June 19th, 2019 Stop 2

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6/20/2019 3

Department

  • f Medicine

Labs and Studies

9.4 12.3 430 3.6 144 136 98 19 1.5 31 28

LFTs: AST 78 ALT 114 tbili 1.2 AP 68 INR: 1.2 Lactate: 3.2 BCx x2: no growth Ucx: no growth CXR: clear lungs

Department

  • f Medicine

Additional Labs and Studies

  • Stool studies:

Shigella, salmonella, e.coli: negative

  • C. diff: negative

Ova & parasites: negative

  • HBsAg positive
  • HBcAg positive
  • HBV viral Load: 2.5 billion copies per milliliter
  • HCV antibody negative

Department

  • f Medicine

Imaging

CT abdomen Mesenteric inflammation with fat stranding, edema and thickening of the bowel wall along the distal sigmoid and rectum. Findings concerning for ischemic colitis. Upper Endoscopy Erosive esophagitis and mild gastritis without active ulcer or bleed. Biopsies taken for H.pylori.

Department

  • f Medicine

Hospital Course

  • Hemoglobin remained stable over the course of

three days and there was no recurrence of hematemesis.

  • Patient continued to have frequent small non

bloody stools.

  • 2 episodes of fevers recorded on day 1 & 2.
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6/20/2019 4

Department

  • f Medicine

Discharge Diagnoses & Hospital Course

  • Ischemic Colitis

– Patient was presumed to have ischemic colitis – Treated with bowel rest, IVF, IV Ceftriaxone and Metronidazole

  • Gastritis & esophagitis

– Gastric bx: non-specific inflammation, H .pylori (-) – Initially treated with IV PPI & then oral PPI – No recurrence of hematemesis. – Hgb remained stable at 9.3.

  • Discharged after 3 days with outpatient GI &

Hepatology follow-up.

Department of Medicine

Clinical Problem Solving

June 19th, 2019 Stop 3

Department

  • f Medicine

2 Months Later….

  • BIBA after a ground level fall on the street
  • CC: leg weakness that started during the prior

hospitalization and continued to worsen post discharge.

  • Has fallen several times over the past 2 months &

has started using a cane.

  • Due to weakness and difficulty ambulating he had

missed his GI and Hepatology appointments.

  • Also weakness in his hands, now daughter helps

him get dressed.

Department

  • f Medicine

Review of Systems

  • Bilateral foot & leg pain that wakes him up from sleep
  • Ongoing fevers & sweats
  • Ongoing abdominal pain, especially after eating
  • Occasional diarrhea, sometimes with small amounts
  • f blood.
  • Severe fatigue
  • Weight loss
  • All other ROS are negative
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6/20/2019 5

Department

  • f Medicine

Physical Exam

BP 160/92 | Pulse 108| Temp 38.5C| RR 22 |SpO2 98% GEN: frail looking male with bitemporal wasting, A&O x 3 in no apparent distress HEENT: dry mucous membranes, pale conjunctiva HEART: regular tachycardia, S4, no m/r/g LUNGS: clear to auscultation bilaterally ABD: soft, diffusely tender. DRE: brown stool, guaiac + EXT: Interosseous muscle wasting in the R hand, calf circumference L< R NEURO: 4/5 wrist extension on the right, 3/5 right finger

  • abduction. Left ankle unable to plantar or dorsiflex. Unable

to feel light touch on dorsum of left foot, DTR 1+ in left

  • ankle. On walking the patient was observed to have a left

foot drop. Otherwise unremarkable neurological exam

Department of Medicine

Clinical Problem Solving

June 20th, 2018 Stop 4

Department

  • f Medicine

Labs and Studies

7.8 18 664 3.0 126 128 98 19 1.3 28 23.4

LFTs: AST 72 ALT 158 tbili 1.4 AP 89 Albumin: 1.2 INR: 1.4 Lactate: 1.9 ESR: 68 CRP: 16.5 CK: 43 (normal) UA: bland Blood gram stain: negative; culture: no growth

Department

  • f Medicine

Additional Labs

  • HIV negative
  • ANA 1:80
  • dsDNA negative
  • ANCA: 1:20 pANCA pattern
  • SPEP: slight elevation in the gamma globulin level

without a clear monoclonal band.

  • Cryoglobulins: none seen
  • Complements: mildly elevated C4, normal C3
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6/20/2019 6

Department

  • f Medicine

Additional Labs and Studies

  • EMG

– Asymmetric, axonal sensory and motor polyneuropathy, primarily affecting the legs but also involving the right arm.

  • Neurology & Neurosurgery consulted
  • Patient undergoes biopsies of the left peroneal

nerve.

Department of Medicine

Clinical Problem Solving

June 20th, 2018 Stop 5

Department

  • f Medicine

Hospital Course

  • Acute episodes of bright red blood per rectum on

hospital day 3.

– BP 86/54. HR 132 T 39 RR28 O2: 96% on RA – CV: weak peripheral pulses, cold extremities, tachycardia – Abd: tenderness LLQ without guarding. DRE: bright red blood

  • Resuscitated with IVF & 4 units of PRBC
  • EGD: fresh blood in the stomach and adherent

clot in the fundus over a possible superficial ulcer (treated endoscopically)

Department

  • f Medicine

Upper GI Endoscopy

  • Fresh blood in the stomach and adherent clot in

the fundus over a possible superficial ulcer.

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6/20/2019 7

Department

  • f Medicine

Hospital Course

  • Maroon stool persisted after endoscopy and

patient required 6 more units of blood.

  • Repeat endoscopy 2 days later showed a

Dieulafoy's lesion in the fundus of stomach with adherent clot. The surrounding mucosa was edematous with submucosal hemorrhage

  • Biopsies were not taken due to high risk of

bleeding

Department

  • f Medicine

Gastric Dieulafoy's Lesion

Department

  • f Medicine

36 hours later…

  • Recurrent hematemesis and hypotension.
  • A diagnostic procedure was performed…

Department of Medicine

Clinical Problem Solving

June 19th, 2019 Stop 6

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6/20/2019 8

Department

  • f Medicine

What is the most likely diagnosis?

  • A. Endocarditis
  • B. Syphilis
  • C. Tuberculosis
  • D. Polyarteritis Nodosa
  • E. Microangiopathic polyangiitis
  • F. SLE
  • G. Ehlers-Danlos Syndrome
  • H. Atrial Myxoma

Endocarditis Syphilis Tuberculosis Polyarteritis Nodosa Microangiopathic polyangiitis SLE Ehlers-Danlos Syndrome Atrial Myxoma

0% 0% 0% 6% 0% 0% 38% 56% Department

  • f Medicine

CT Angiography

Diffuse irregularity of the branches of the SMA with multiple narrowing & pseudoaneurysms. Fusiform pseudoaneurysm in the main splenic artery with contrast extravasation from several short gastric arteries nodes.

Department

  • f Medicine

Department

  • f Medicine
  • Peroneal nerve biopsy

– Active vasculitis with ischemic damage to the nerve and acute axonal degeneration

  • Putting it all together:

– Medium vessel microaneurysms on angiography – Peroneal nerve vasculitis – Hepatitis B infection

  • Diagnosis: Polyarteritis Nodosa
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6/20/2019 9

Department

  • f Medicine

Polyarteritis Nodosa

  • Kussmaul and Maier described Polyarteritis nodosa in

1866

  • PAN is a necrotizing vasculitis affecting medium-size

arteries

  • Up to 75% of patients have PNS involvement

– mononeuritis multiplex

  • While the renal vasculature is commonly affected, the GI

tract is involved in 2/3 of the patients

  • GI hemorrhage occurs in about 6% of patients with PAN
  • Classic finding on angiography is defuse mesenteric

microaneurysms

Department

  • f Medicine

American College of Rheumatology Criteria for Diagnosing PAN

Presence of three out of these ten suggests for a positive diagnosis

Department

  • f Medicine

Polyarteritis Nodosa & HBV

  • About 1/3 of PAN cases are associated with HBV
  • Polyarteritis nodosa caused by HBV infection requires

both immunosuppressive and antiviral therapy

– driven by viral replication and immune-complex deposition

  • Treatment of HBV-associated PAN is challenging

– Need immune suppression to stop tissue damage caused by vasculitis – Immune suppression can promote uncontrolled viral replication and fulminant hepatitis.

  • To balance the above concerns, simultaneous immune

suppression, antiviral therapy, and plasma exchange to eliminate immune complexes is often indicated.

Department

  • f Medicine

Back to our patient…

  • Endoscopic Embolization

– The splenic artery was embolized with N-butyl cyanoacrylate glue. – Postembolization angiography demonstrated total occlusion of the active bleeding vessel.

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6/20/2019 10

Department

  • f Medicine

Clinical Course

  • Initially treated w/ entecavir, tenofovir and steroids.
  • Unfortunately, he experienced another episode of

hematemesis associated with hemodynamic instability 3 days later & underwent a total gastrectomy.

  • Post-op: plasma exchange & continued antivirals
  • He had an immediate virologic response, resolution
  • f fever, and moderate improvement in neuropathic

symptoms.

Department

  • f Medicine

Clinical Course

  • 2 weeks after completing plasma exchange, he

was started on IV Solumedrol & Cyclophosphamide with further improvement in symptoms.

  • The leg weakness gradually improved the

course of a year and his steroids were tapered.

  • He was continued on antiviral therapy

indefinitely.

Department

  • f Medicine

Conclusion

  • Vasculitis is rarely suspected in the course of

investigation of an upper gastrointestinal bleeding.

  • A search for alternative diagnoses when none
  • f the common causes of upper GI bleeding

such as peptic ulcer, varices, esophagitis and neoplasm are discovered is imperative.