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Thieves’ Market 2013

J. Scott Neumeister MDAssociate Professor, General Internal MedicineThe Nebraska Medical Center

Back Pain

A 48 year old male presents with a 3 month historyof low back pain.

His pain started 3 months ago after getting jarredwhile on a roller coaster ride. He has been takingTramadol and seeing a Chiropractor without anyrelief. The pain is worsening and he now has troublewalking.

He has not been able to work at his job as electrical contractor for this time period.

He has been bruising easily on his arms and legs without defined trauma. He notes his legshave been swollen. Furosemide has nothelped reduce the swelling.

He has noticed some difficulty passing his urinewith rare incontinence.

Married. 3 kids. Electrician. No Tobacco. Rare ETOH. No drugs.

PGM had breast cancer

Tramadol, Furosemide

No allergies

Appendectomy years ago.

98.7 88 16 122/60

Takes 3 people to stand him upstrength, reflexes, sensations intactproprioception normalpainful with any movementBack tender along vertebrae diffusely

Bruising on arms and legs, no other skin abnormalitiesEdema legs – symmetric, below knees

Prostate normalNo lymphadenopathy

14.211.7 179 141 105 19 108 41 3.4 27 0.9 9.5

AST/ALT normalAP 217Bili 1.3TSP 4.9Alb 2.9

B12 normalTSH normal

T5, T7 – L5 compressionfractures.

Some new, some old,some new on old

UA normal (no protein)Sed rate 2

SPEP normalImmunofixation normal

Bone Marrow Bx normal

Vitamin D 60

PTH 30 (normal)PTHrp negative

Heavy metal screen normal

Dexa – T score -2.8 Z score -2.8

Cortisol 28 (< 18)

Testosterone 32 (180 – 900)

Urinary cortisol 445 (<60)

Salivary gland cortisol elevated X 3

LH, FSH, prolactin, ILGF-1, free T4 normal

ACTH 159 (<46)

MRI Sella – No adenoma noted“minimal signal intensity heterogeneity”

CT chest – normal

CT abdomen – nodular adrenal gland

Petrosal sinus sampling - ACTH 5437

Pituitary exploration –

Possible adenomatous tissue resected

Path consistent with fibrosis

Follow up urine cortisol normalSerum cortisol 11ACTH 61 (<46) - (repeat MRI sella pending)

ACTH Dependent Cushing’s Disease

Petrosal sinus sampling IF adenoma less than 6 mm? If the side can be localized accurately

Cure rates with surgery - 0 – 80%

Difficult to prove cure, follow annually

Repeat surgery, irradiate, adrenalectomy are future options

Cough

A 59 year old Caucasian male has a 5 monthhistory of a non productive cough

He has had progressive SOB. He is having difficultywalking up a flight of stairs. He still carries 80 poundbags at work.

He has worked as a forklift operator for the past 4 years. He is exposed to salt dust, feed additive, andfertilizer dust.

He has lost 80 pounds by following a gluten free/high protein diet

He took anabolic steroids as a bodybuilder in the70’s and 80’s

ROS: NO feverchest painpalpitationstravelpetshx of heart/lung diseaseswollen jointsedemablood loss

PMH: Solitary Kidney. Rotator cuff surgery. HTN.

FM: Dad with unknown type of cancer.

SOC: Girlfriend. No tobacco, etoh, drugs

All: Bee stings, PCN – anaphylaxis

Meds: Symbicort (didn’t help)Hydralazine 25 mg TIDMetoprolol 25 mg BIDAlbuterol MDINiacin 1 gm BIDCialis 10 mg

145/91 73 36.1 16 221 lbs 6’2”Neurologic normalEars normalEyes – clear, no injectionNo LNThyroid Normal Lung: Bilateral RalesNo rashes basesNo swollen jointsHeart normal

9.4 138 107 41 107 lft’s normal6.6 250 4 26 3.3 8.9 alb 2.6

UA Large blood baseline Cr. 1.7 Mild protein 50 RBC No WBC No casts

O2 sat, EKG, ck, troponin, tsh all normal

echo EF 60% LVH, La mild dilated

FEV1 3.65 93%FVC 4.39 91%DLCO 99%

CT Bilateral ground glass opacities in a centrilobular distribution

Bronch – No blood, lavage normalViral panel negativeHisto Ag negative

Hemocult negB12, folate normal

Iron 6 Ferritin 84 TIBC 259

LDH normal, Haptoglobin normal

DAT IgG +, C3 neg

Sed rate 86crp 5.9

Epo 28 (4-27)

ANA 1:1280dsDNA +anti-histone +ANCA+Serine Protease 3 + (assoc with c-anca)Myeloperoxidase AB + (assoc with p-anca)C3 84 (90-180)C4 normalGBM normalcryo, hiv, hep B/C negativeUrine protein 500 mgUS – atrophic left kidney, normal right kidney

mild splenomegaly.

Renal bx – Focal necrotizing glomerulonephritiswith mesangial immune deposits

“full house” mesangial depositsIgG, IgM, C1q, C3, Kappa, Lambda granularstaining

Albumin linear staining

No IgA staining

Hydralazine induced vasculitis/Drug induced Lupus

Main therapy is cessation of drug howeverHydralazine induced disease typically requires therapy

Treated with steroids and cyclophosphamidewith near resolution of renal function

10% of patients taking Hydralazine get drug inducedLupus

Rare to have renal involvement with drug inducedLupus

Rare to have immune complexes in Drug inducedvasculitis

Typically p-anca +, rare to be c-anca

Weakness

A 77 year old Caucasian male notes several monthsof progressive weakness

When he first presented (6 months ago) he was discovered to have gallstones. His gallbladderwas removed and he felt better for a brief periodfollowing surgery.

He has since lost 35 pounds. He is not eating well.No specific symptoms

He has had to have his blood pressure meds stoppedor lowered due to low blood pressure

He notes episodes of dizziness upon standing

SOB with exertion

The weakness is worse in his legs

Feels like his feet go “numb”

Muscle/joint pain at baseline with his “arthritis”

NO chest painpalpitationsvertigo/imbalancediarrheabladder sxfeverstravel

Soc: Trucker/chemical mixer. MarriedLives near Kearney, NE80 pk yr tob No etoh/drugs

Fm: Dad died of LeukemiaMom died of ovarian cancerSister has thyroid disease

All: None

PMH: Rotator cuff repair, Appy, HTN, GERD

Meds: ASA 81 mgMetoprolol XL 25 mgMVIOmeprazole 40 mgOxycodone/apap 5/325 (2-4 a day)Biotene Dry mouth rinseSimethicone as neededSpironolactone 25 mgZolpidem 10 mgLisinopril 2.5 mg (has been held)Albuterol MDI as needed

104/63 73 35.6 20 76.9 kgThyroid enlargedNo LNCTARRRCranial nerves normalRhomberg normal4/5 strength arms3/5 strength hips4/5 strength lower legDiminished sensations lower extremities – light touchReflexes 1+ patellar, absent ankle

Sats 95% 7.47/22/63 EKG Normal Trop Normal

10.44.2 135 N 45 L 36 M 10 Eos 5 Bas 3 31

CXR atelectasis L base

CT emphysema. small effusions. splenomegaly

ECHO PA pressure 40. trivial valvulopathy. EF 60%

130 93 24 55 alb 2.7 protein 6.04.2 21 1.4 9

TSH 0.07 (0.4 – 5)

CK 5

sed rate 44crp 18

Free T4 0.3 (0.5 to 1.5)

TSI negTPO Ab neg

US multiple small nodules favoring benign etiology

SPEP negImmunofixation neg

pre-albumin 5.1 (18 -38)

Cortisol 7 (6 – 22)

B12, folate normal

Iron 23 (low)TIBC 183Ferritin 442

Vit A 83 (300-1000)Thiamine 70 (70-180)Vit D 26 (30 – 200)Vit E normal

ACTH 11 (0-46)Cortisol 7.1 30min 13 60min 13

Testosterone <10

FSH 4.9 (1.3-19)LH 1.7 (1.3-19)Prolactin 17 (< 13)ILGF 16 (39-184)

MRI pituitary – normal. Brain small vessel disease.

Panhypopituitarism? if due to hypotension peri/post operative for hisgallbladder.

Placed on steroids, testosterone, thyroid,vitamins A, D, and thiamine

He felt better…..but only for a brief period

He presents with ongoing weakness. Now havingdifficulty standing without a 2-3 person assist

Exam significant for 3/5 strength in his major musclegroups (legs worse than arms)

He is taking his meds. Repeat lab data indicatesa normal T4

CK 5sed rate 44crp 18

MRI SPINEC5-5 spinal stenosis. Multilevel neural impingementT spine – mild djdL4-5 neural abutment. Multilevel djd

Aldolase 11.9 (1.5-8.1)

LP – no oligoclonal bands, cytology neg

EMG (right arm/leg)

Proximal myopathy, peripheral neuropathy

Muscle Bx:

Intravascular Large B-cell Lymphoma

RAREPresent with CNS/neuropathy in CaucasiansPresent with bone marrow findings in Asians50% 3 year survival

Joint Pain

A 25 year old female notes red, swollen joints ofher wrists, knees, and ankles

Her joint pain started 3 months ago. It occurred during the first week of her cycle. It has recurredeach month in a cyclic fashion.

She stopped her birth control pills a few weeksbefore the first event.

She has been on and off OCP’s since she was 16 –started and stopped for no significant medicalreason.

She saw a physician who prescribed hersteroids.

She did not have any problems reaching the summitof Mount Kilimanjaro (Tanzania), however she noticed her fingers blanched at the summit.

The finger changes had occurred previously duringcold Boston winters

Her joint pain keeps recurring and is interfering withher marathon training

She notes also during the last few months she getsbumps on her arms and fingers that ulcerate

She gets an intermittent sore throat. Approximatelytwice a month. She was treated for Scarlet feverin 2005 but developed a rash after taking penicillin.

PCN – caused a rash

Prednisone 5 mg for 2 to 3 days for a flare

From Boston. Now lives in OmahaNo tobacco or drugs.Rare AlcoholMonogamous relationshipWorks in public relations

Brother had scarlet fever also

Mom with Graves’Mom has intermittent joint swelling – gets betterwith prednisone

ROS:Notes a red rash on her arms in 2 different placesthat has now resolved

Sometimes has palpitations with the onset of hermenses/nodules

NO fevers, hair loss, bowel changes, mouth sores,back pain, urinary complaints, chest pain, orcycle changes

98/68 16 49 36.5 5’3” 111 lbs

Pharynx normalNo LNthyroid normalRRR, CTANo HSMSkin – no rashesbumps on her right elbow2nd PIP right scarred lesion (prior bump)4th DIP left scarred lesionNo joint effusionsNo trigger points

15.2 137 101 11 838.8 245 3.9 26 0.8 9.6 41

AST 20 Alb 4.6 Sed rate 7ALT 17 pro 7.9 crp normalAP 59Bili 0.7

TSH normalUA normalPreg negative EKG S. Brady

Echo – mild thick Mitral V.

ANA 1:40ssB +

NormalRFCCPACEssAJOSclRNPSMcomplement

Reubella immune

HIV negParvo IgM negParvo IgG positive

Hep B negHep C neg

RPR neg

Rapid strep negThroat culture neg

ASO 199 (0-333)

Dnase B Ab 399 (0-120)

What do you think is wrong??

PolyarthritisSubcutaneous nodulesRed circular rash(es)

arthralgiasevidence of antecedent strep infection

Rheumatic FeverThroat cultures are usually negativeASO titers fall after the first few months

Nodules are the rarest findingsTypically on the elbow (RA are several cm below)

Responds quickly to anti-inflammatories

PCN allergic - Sulfadiazine 1gm a day