Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha @sargsyanz @StephVSherman

Chat recap of the #ClinicalPearls #VirtualMorningReport

July 29th Episode 103: clinicalproblemsolving.com/morning-report…

W / Reshon Hadmon, Sonia Silinisky, & @AchantaAditya

Let’s start with a problem representation:

A 30 y/o F presents w/ a 6-mon history of a nonproductive cough worse w/ activity, a recent-onset fever, blurred vision, dry eyes who was found to have uveitis, erythema nodosum, & crackles on PE along w/ hilar LAD & hypercalcemia

Let's start with the cough.

A chronic cough in a 30 y/o? hmmm

Cough thinking about a pulmonary process (anywhere from nose to alveoli) but also thinking about GI and cardiac etiologies causing cough as well

Is this fever part of this chronic process or is a new acute process complicating the chronic

Chronic cough is > 8 weeks & 4 conditions account for most cases: upper airway cough syndrome, GERD/LPR, asthma, & nonasthmatic eosinophilic bronchitis. aafp.org/afp/2017/1101/…

2 other common causes of chronic cough are cigarette smoking and medication-associated, e.g. ACEI

This time course is definitely more chronic. There sounds like there is inflammation present w/ fevers.

With time course, leaning more toward inflammatory/autoimmune cause.

Could also consider indolent infection.

Malignancy seems less likely.

Also thinking about the background and immune status.

ROS will be helpful as well to help tease out if localized vs more systemic process.

If the patient is from Arizona --> Coccidiomycosis!!

Also curious about blurred vision if it is a CN problem or a possible uveitis, scleritis, or episcleritis. That would help drive ddx.

RA can present w/ dry eyes, uveitis, joint pain

If there is redness or the eye, need to check visual acuity, looking for ciliary flush, & then checking response to phenylephrine drops (to see if redness improves) will be helpful.

Here is a full table of uveitis causes: retina-specialist.com/article/uveiti…

Remember that RA can also affect the lungs causing pleural effusion, interstitial pulmonary fibrosis, & trapped lung syndrome

What is lung entrapment? It refers to an inflammatory rind that forms around lung parenchyma. when U remove an effusion w/ thora, the lung cant re-expand

"shrinking lung syndrome" is a complication of SLE but not RA. (Maybe some foreshadowing here for another day)

Add to the PR bilateral LE nodules that are painful.

EN, uveitis+ fevers + lung involvement. Sounds like sarcoid, but fungi & mycobacterial infections can mimic this.

She does work in a prison and is from Arizona but she is on vacation in Grenada in this case

a word for ‘prison-related’ is desmoteric

Add to the PR hypercalemia of 12:

High calcium, wondering about granulomatous diseases, although could also be bone infiltration ect.

Bilateral hilar adenopathy + erythema nodosum + joint pain is the triad of Lofgren's syndrome in sarcoidosis

Lofgren syndrome is a clinically distinct phenotype of sarcoidosis, first described in 1946 by Swedish pulmonologist Sven Lofgren.

In contrast to the often-insidious onset, slow disease progression & chronic disease course typical of sarcoidosis

Lofgren’s presents acutely & portends a favorable prognosis.

It typically presents in younger pts w/ acute onset erythema nodosum (EN), b/l hilar LAD, fever, & migratory polyarthritis, & w/o granulomatous skin involvement.

ncbi.nlm.nih.gov/books/NBK48231…

hyperCa consistent with granulomatous process - supports sarcoid, disseminated fungal, & TB if it is a 1,25-OH Vit-D driven process

ACE levels are fairly non-specific and can be elevated in other granulomatous conditions

ACE will be ⏫ in 50%-80% of those w/ active sarcoidosis

The finding of an⏫ACE level helps to confirm dx

A nml ACE level cant be used to rule it out

There is no correlation between ACE level and sarcoidosis prognosis

Many studies have shown that patients w/ ⏫ ACE levels suffer from a more severe dz, ncbi.nlm.nih.gov/pmc/articles/P…

The PFTs are non-obstructive and appear restrictive and the DLCO is 🔽

Anyone else need a quick refresher on #PFTs, check out this Dx Schema - Approach to PFTs clinicalproblemsolving.com/dx-schema-appr…

An important exception in which a normal FEV1/FVC still represents obstruction:

Decreased VC in the setting of a normal TLC.

The infamous ATS obtuse line as I call it, a lot of people with airflow obstruction fall in this pattern.

A biopsy was performed showing non-caseating granulomas

Acid fast -

HIV -

Final dx...Sarcoidosis

She was started on oral pred and steroid eye gtts for her uveitis

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