Thread by @RosenelliEM

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

August 17th Episode 119: clinicalproblemsolving.com/morning-report…
W / @MohitHarshMD @KromerHaylie & Ninand Bhat

Let's start with an initial problem representation:

A 75 y/o M w/ a PMH of COPD, CAD, & aortic valve replacement p/w 2 weeks of dyspnea on exertion, 1 month of LE edema, 20 lb weight loss & recent onset PND and Orthopnea

invoke the dyspnea pyramid (cardiac, pulmonary, anemia, metabolic) but addition of progressive edema and weight gain concerning for cardiac pathology

whenever we see dyspnea on exertion and bilateral LE edema we jump straight to CHF

more features concerning for CHF but thinking also about liver and kidney leading to excess fluid as well

possible mechanical hemolysis from bio prosthetic valve contributing to dyspnea from anemia

Does the SOB improve when sitting up? concern also for hepatopulmonary syndrome

Prence of constitutional symptoms to suggest inflammation

How long after sitting up can he lie back down - very important in defining PND.

(PND) is a sensation of SOB that awakens the pt, often after 1- hours of sleep, and is usually relieved in the upright position.

PND article from prior tweet. ncbi.nlm.nih.gov/books/NBK213/#….

Does he have Bendopnea as well?

alcoholism/liver dysfunction could lead to third spacing?? = weight gain

There are many reasons to awake at night and sit up. COPD, sleep apnea, both allow immediate recumbency -

Add to the PR physical exam: BP 170/90, he is chronically ill appearing, peri-orbital edema, exp wheezes, 2+ pitting edema, 2-3 cm gluteal mass & 4-5 cm thigh mass

The preorbital edema suggests nephrotic syndrome or thyroid disease

He looks volume overloaded but there are no signs of volume overload in the lungs. hmmm

Would want to see the albumin, u/a, urine protein/creatinine if albumin decreased

Don't forget about amlodipine assoc LE edema

also wondering if that mass is some kind of sarcoid/amyloid/malignancy that contributes to nephrotic syndrome

subcutaneous nodules + volume overload, also consider Rheumatic disease

isn’t there a weird parasitic infection that can cause periorbital edema from eating pork?

Trichinela spiralis can do it, ncbi.nlm.nih.gov/books/NBK53851…

A soft tissue sarcoma- can originate from cardiac and are soft. In the heart can cause congestion/pericardium

Add to the PR some labs: Nml WBC, hgb 9.7, nml plts, elevated Cr from baseline at 1.63, a Gamma gap, NT-BNP of 8000, nml trop, UA: 3+ protein, 24 hr urine 9g

CXR: left pleural effusion with nodules in the left lung

There is a huge gamma gap!! ncbi.nlm.nih.gov/pmc/articles/P…

We have renal dysfunction, anemia, volume overload, & a protein gap. will want to determine monoclonal from polyclonal

And we know that 3 + protein has a strong association with increased ACR or PCR

Conversion of Urine Protein–Creatinine Ratio or Urine Dipstick Protein to Urine Albumin–Creatinine Ratio for

Use in Chronic Kidney Disease Screening and Prognosis: An Individual Participant–Based Meta-analysis: Annals of Internal Medicine: Vol 0, No 0 acpjournals.org/doi/10.7326/M2…

Is this amyloid? autoinflammatory disease? Waldenstrom’s? any history of hep C?

he would be in the age group that has increased risk of chronic HCV infection

He does have a PMH of IV drug abuse and that can also result in amyloidosis

Can we get some BCx...

They were negative on admission

Echo showed no evidence of endocarditis but the presence of diastolic dysfunction

PET scan showed hypermetabolic gluteal mass

And you guessed it. We need a biopsy.

And the final Dx is Minimal Change Disease secondary to an extranodal marginal b cell lymphoma

MCD occurs in only ~0.4% of lymphomas, so incredibly rare, but always taught on UWorld

pubmed.ncbi.nlm.nih.gov/21594766

Teaching points illustration by @sukritibanthiya

Minimal change nephrotic syndrome (MCNS) is the most frequent glomerular disease

It is an acquired glomerular disease of unknown origin, characterized by heavy proteinuria without inflammatory lesions or cell infiltrations.

ncbi.nlm.nih.gov/pmc/articles/P…

The pathogenesis of this disorder remains poorly understood; but there is evidence to suggest an immune origin

MCNS is caused by a putative circulating factor, which increases glomerular capillary permeability and leads to podocyte cytoskeleton disorganization and proteinuria

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