Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha @andressa__k @sargsyanz @StephVSherman @OpsBug @fernandbteich
Chat recap #ClinicalPearls #VirtualMorningReport
June 24th Day 80 clinicalproblemsolving.com/morning-report…
Case Overview @haematognomist
Let's start with a Problem Representation:
A 6o y/o F presents with 10 yrs of SOB, recent falls the last few months, increasing fatigue, constipation (1 BM every 8 days), and new-onset AMS found to have pancytopenia, 🔽Na, 🔽Glu, 🔽 Free T4, 🔽cortisol
From the get-go: Gait difficulties for 7 days, AMS, constipation
Enter MIST pneumonic for AMS
Hypercalcemia links constipation and AMS but Hyper CA doesn't explan dyspnea
she will have polyuria w/her hypercalcemia
ncbi.nlm.nih.gov/books/NBK27912…
Could her anemia be from Bone marrow hypoplasia d/t pesticide exposure given where she lives and occupation?
Pesticide exposure is associated with lymphoma, leukemia, and a Parkinson’s like disease
scielo.br/scielo.php?scr…
with the constipation & patient location, what about Chagas disease.
Another common manifestation of Chagas disease in the gastrointestinal tract is chagasic megacolon. Chronic constipation is the main symptom related to megacolon
ncbi.nlm.nih.gov/pmc/articles/P….
Something else to think of are endemic mycosis, the endemic mycosis of choice would be Paracoccidioidomycosis since she is from Brazil, cdc.gov/fungal/disease…
Cardiac involvement could explain the dyspnea- Chagas can cause heart block
Chagas can take decades to cause these kinds of manifestations
Usually very slow, asymptomatic for a long time (like 20 years I think), ncbi.nlm.nih.gov/pmc/articles/P…
An example of an acute infection with Chagas is a chagoma
A review on the treatment of Chagas ncbi.nlm.nih.gov/pmc/articles/P…
Cardiomyopathy can cause LV clots & emboli. Decomp CHF can cause delirium & Arrhythmias
Could this BM issue be from a GATA2 mutation predisposing to mycobacterium, possibly alveolar proteinosis ncbi.nlm.nih.gov/pmc/articles/P…
would also consider Trichinellosis and TB thinking about infectious causes, ncbi.nlm.nih.gov/pmc/articles/P…
A little hypothermic, constipation, hyporeflexia making us think about hypothyroidism
hypothyroidism presents with delayed relaxation on reflex testing
Hypothyroid can cause hyponatremia/ and anemia
Chronic lead toxicity, basophilic stippling on peripheral smear
Does she have a Queen Anne sign? pubmed.ncbi.nlm.nih.gov/17551609/
Looks like Metabolic is the winner of the MIST mnemonic
A fav CP Solvers schema, hyponatremia , we need serum osm, urine osm and nahttps://images.app.goo.gl/aZWi5KE5EV3Je5d17
TSH is relatively given her low free T4
This can also cause hyponatremia and the hypoNa can cause the AMS
Could this be a pituitary process?
Central hypo due to infectious? infiltrative? invasion? or infarction?
We need a cortisol level!
Seems like pan-hypopit could be at play, very interesting w/ normal brain imaging, although should do dedicated pituitary MRI
As a regular MRI doesnt r/o a Pituitary lesion
Need to remember not to correct hyponatremia too quickly to prevent demyelination in CNS, no more than 10-12meq/24hrs
Also wonder how the bone marrow hypoplasia was diagnosed & when. If an infiltrative disorder could be effecting the marrow too
Is this lung nodule related?
If we are going to give thyroid, we will have to also give steroids also at first, ncbi.nlm.nih.gov/pmc/articles/P…
thyroid replace revs up metabolism, causes drop in cortisol
you can get acute MI if you replace thyroid too quickly
Next step: random cortisol - should be 🔼if 🔽then do a STIM test
If is this is a central lesion, you could see a normal STIM test if you give ACTH in the early phase because the adrenal gland can respond. Later, you get atrophy of the adrenal gland & can see a blunted response
If there is an infiltrative disease (amyloid, infection, etc) that unifies bone marrow and pituitary
Good review on “Endocrine Disruptor Pesticides” ncbi.nlm.nih.gov/pmc/articles/P…
If this is TB, could be miliary, if she has pancyto, infiltration of adrenals would cause electrolyte abn
Multiple pivot points in this case but this looks like like panhypopit. statpearls.com/kb/viewarticle…
Final dx: Sheehans Syndrome, statpearls.com/kb/viewarticle…
It can present acutely or chronically, ncbi.nlm.nih.gov/pmc/articles/P…
An empty sella is seen in 70% & a partially empty sella in 30%
It is generally diagnosed several years postpartum; therefore, it has been recognized as a chronic condition. Here is a case w/ acute manifestations ncbi.nlm.nih.gov/pmc/articles/P…
Usually found w/ agalactorrhea, ncbi.nlm.nih.gov/pmc/articles/P…
Teaching points @sukritibanthiya
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