Thread by @DoubleDawgMD

A 50 yo F presents with 8 weeks of fever + headache!

Jumping right in with today's #CPSmorningreport
@CPSolvers

1/

@EmmaHLevine w/ initial thoughts on HA + fever - is HA primary? Or secondary?

If secondary - is it intracranial (vascular, CSF, tumor, infectious) or extracranial (meds, withdrawal, TMJ, ocular)?

#CPSmorningreport
2/

A tale of 2 mnemonics:
SNOOP- (Systemic sx, neuro sx, onset (sudden), Old (>50), prior/positional as HA red flags

IMADE approach to fever - infxn, malignancy, autoimmune, drugs, endocrine

#CPSmorningreport
3/

Additional history reveals that fever usually starts at 11 am. Headache is boring, severe, progressive, located behind the eye.

She has a bullet fragment from previous GSW. Only other PMH is HTN. Fam Hx +psoriatic arthritis.

#CPSmorningreport
4/

Our discussion is revolving around the chronicity and cyclical nature of the symptoms as our pivot points right now.

Concern for autoimmunce/cyclical fever syndromes > infection at this point. Also considering intracranial etiologies.

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5/

Physical exam is pertinent for L scalp tenderness. Otherwise no neuro deficits. Afebrile. Obese.

WBC 2.1
ANC 1.21
Plt 109
Cr 1.28
AST 217
ALT 114
AlkPhos 82

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6/

The above aliquot makes GCA the do-not-miss diagnosis by exam alone. ESR will be necessary. That being said, the bicytopenia and transaminitis make Tic borne illness climb near the top of our differential. Bone marrow may play a role...

#CPSmorningreport
7/

Remember, if you are concerned about bone marrow, think

Intramedullary (stem cell, granulomatous, infiltrative, suppressed, lack of materials)

vs

extramedullary (infection)

#throwback

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8/

Massive ID and rheum workups were sent.

-normal LP
-no HIV, Hepatitis, mycoses, ticborne disease
-negative ANA, ANCA, SMA, AMA, CCP, RF
-ferritin 6900
-CPK 636
-LDH 896
-hapto 46

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9/

With this information, we see our acute phase reactant is sky high! Our LDH tells us that there is turnover of soooome type of LDH containing cell, be it blood, liver, spleen, malignancy, etc.

This aliquot has shifted our discussion towards malignancy.

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10/

Fibrinogen low. D-dimer high. Triglycerides 338.
Bone Marrow Biopsy with frequent hemophagocytosis.

We seem to be diagnostically circling around HLH....with @TxID_Edu bringing up the important point- if this is the Dx, what is the trigger?!

#CPSmorningreport
11/

Then @rabihmgeha drops this absolute gem:

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12/

PET-CT showed numerous and diffuse hypermetabolic intramuscular lesions.
At this point, all of us are pretty much out of our depth. Tissue is the issue...........

Tissue biopsy showed a final diagnosis of peripheral T cell lymphoma.

#CPSmorningreport

Fin/