Thread by @DrSamanthaWang

1/9: A woman presents with diarrhea x 2 weeks that woke her from sleep. I love this fantastic framework for chronic diarrhea by @LindseyShipley8

2/9 We reviewed her admission EKG. What do you notice?

3/9 #MedTwitter: What’s your ddx for low EKG voltage? Think back to physiology. The space between EKG leads &❤️ can be filled with: 𝗳𝗹𝘂𝗶𝗱 (pleural/pericardial effusion), 𝗮𝗶𝗿 (PTX, COPD), 𝗳𝗮𝘁, 𝗶𝘀𝗰𝗵𝗲𝗺𝗶𝗮 (dead tissue) or 𝗶𝗻𝗳𝗶𝗹𝘁𝗿𝗮𝘁𝗶𝘃𝗲 processes.

4/9 But is this all just noise? Remember, she came in for diarrhea! 💩

5/9 The woman was skinny. Her previous TTE showed LVH. Residency taught me to always consider amyloidosis when we see low EKG voltage but LVH on echo. @cardionerds @Ron_Witteles @AmitGoyalMD

6/9 In the US, amyloidosis primarily exists in 2 flavors: AL (associated w/ plasma cell neoplasms) or ATTR (hereditary or wild type). To begin our work up, we sent off SPIE+FLC, which returned w/ a monoclonal λ light chain band.

𝗕𝘂𝘁 𝘄𝗮𝗶𝘁, 𝗱𝗶𝗱𝗻’𝘁 𝘀𝗵𝗲 𝗰𝗼𝗺𝗲 𝗶𝗻 𝘄𝗶𝘁𝗵 𝗱𝗶𝗮𝗿𝗿𝗵𝗲𝗮? Signal or noise?

8/9 She underwent a colonoscopy for her diarrhea which showed 𝘩𝘦𝘢𝘷𝘺 amyloid deposition. Her bone marrow biopsy showed a 5% clonal population of plasma cells. Final diagnosis: AL amyloidosis and lamda monotypic plasma cell neoplasm

9/9 Takeaways:
1. Always review a patients admission EKG regardless of chief complaint
2. If you see low voltage on EKG + LVH on echo, think amyloidosis
3. Sometimes signal and noise are part of the same tune.

#MedStudentTwitter #AdviceforNewDocs #Amyloidosis @StanfordChiefs @DxRxEdu @sargsyanz @StanCVFellows