Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

July 27th Day 102: clinicalproblemsolving.com/morning-report…

w/ case presenter @sonyardavey and discussants Leticia Maciel & Andrew Sanchez

Let’s start with a problem representation:

An 84-y/o M with a PMH of CAD with CABG, HTN, hypothyroidism, adeno carcinoma of the duodenum s/p Whipple and chemo currently in remission, & Carpal Tunnel Syndrome (CTS) p/w 10 days of scrotal/leg swelling and fatigue w/o CP or SOB

The scrotal swelling always brings them in!!

With fluid overload: thinking about a problem of heart, liver, or kidneys. Remember to look up!

is the IVC blocked with congestion of internal pelvic veins and leg veins (uncommon)? medication side effect?

CAD/CABG 🔼 risk of CHF

It could also be something like May Thurner,

Malignancy makes us consider hypercoagulability

starting in R femoral & growing up to IVC. @medrants has seen this w/an RCC

this could be a new cancer in the pelvis area (advanced prostate cancer or CRC) w/ compression of IVC

For some reason @RezidentMD already has the wheels turning. "base rate would say not to think too much into CTS but always consider amyloid"

But to start we need a CBC, CMP, UA, dimer, ECG, and CXR to start

How often does carpal tunnel and other deposition from GAG 2/2 hypothyroidism resolve vs persist once the hypot4 is treated?

This article suggests the condition may resolve spontaneously, in parallel with a disappearance of the circulating antibody.
sciencedirect.com/science/articl…

CTS in hypothyroidism may be attributed to the deposition of mucinous material or mucopolysaccharides on the median nerve.

Another article looking into hypothyroidism and CTS, one review says can resolve w/ treatment if caught earlier, if long-standing, ncbi.nlm.nih.gov/pmc/articles/P…

Is the swelling in the testicles per se or in the scrotum - latter is more likely related to systemic issues, whereas former more likely neoplastic

@AnnKumfer reminds us that Norvasc is associated with LE edema but would not expect a lot of scrotal swelling

Prostate cancer in family increases the risk of personal prostate cancer by 3

he can easily have a large prostate cancer mass compressing ivc. jamanetwork.com/journals/jamai…

Add on to the PR of atraumatic bilateral biceps rupture without trauma

To test for distal biceps rupture perform the hook test


the amyloid theory seems to becoming a very valid one

JVP being up and biceps being involved this is a systemic issue

JVP=heart problem. biceps fragility means the mechanism is infiltrate

What about one of the 3 common types of amyloidosis?
Wild-type transthyretin amyloidosis, AL, or AA

It is increasingly recognized as an important cause of heart failure w/ preserved ejection fraction HFpEF

Although the primary manifestation of ATTRwt is cardiac, approximately 50% of pts have h/o of carpal tunnel syndrome, w/ amyloid deposits in the flexor tenosynovium. ncbi.nlm.nih.gov/pmc/articles/P…

is JVP specific to a primary heart pathology? Or could this just be fluid overload?

Well we know that nephrotic syndrome and cirrhosis do not cause a high JVP so this points to the heart.

Also remember that tendon (and aorta) effects can manifest long after FLQ exposure, too.

Spontaneous rupture of the distal biceps tendon is uncommon..

..It has an est prevalence of less than 1 per 1000 persons aged 56 to 74 years.

If heart failure is primarily right-sided, might not have as much dyspnea on exertion, or orthopnea, PND, etc

I'm curious to know how's the kidney, if it's amyloidosis that edema could be due to nephrotic syndrome

usually with nephrotic syndrome, we would have seen facial edema also.

Pearl: With 🔽 albumin, risk of clot 🔼

in nephrotic syndrome highest risk is membranous nephropathy

His labs are mostly all unremarkable, nml renal function and liver function tests. BNP and trop are 🔼

ECG is surprisingly nml w/o LVH for some reason. But could this pathologically normal given his symptoms..

Echo: EF 40% that is restrictive w/severe RV dilation & mod MR/TR

is this amyloid vs chemo induced cardiomyopathy

cisplatin can cause kidney damage and ototoxicity in the chronic setting

His Chemo regimen was Capecitabine and oxaliplatin & have no association with heart failure

5-FU infusions can cause coronary spasms with chest pain

Within our differential, it’s helpful to remember the distinction between what we think is most likely (our leading hypothesis) and the things we want to exclude (our active alternatives), because they are likely enough, serious enough, or treatable enough to be actively excluded

Now what is the next step? Cardiac MR next? Or biopsy? fat pad biopsy?

a biopsy is a definitive diagnosis for amyloid

Come on Congo red stain!!

infiltrative disease --> diastolic dysfunction ---> dilated CM

And an endomyocardial biopsy reveals the final dx.

TTR amyloidosis

Here is a plug for an amazing @cardionerds Cardionerds podcast episode on cardiac amyloid:

What about treatment?

There is a good RCT from NEJM 2018 about all cause mortality benefit for Tafamidis for TTR amyloid, nejm.org/doi/full/10.10…

Teaching points overview by @sukritibanthiya

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