1/n Inspired by RLR: @rabihmgeha & @DxRxEdu...
HLH - @haematognomist & @HannahRAbrams
Two rising interns interested in🩸Heme-Onc & 📚MedEd
Teaching pearls from @NEJM CPC published 6/6/13
Dx spoilers below! @MedTweetorials
HLH - @haematognomist & @HannahRAbrams
Two rising interns interested in🩸Heme-Onc & 📚MedEd
Teaching pearls from @NEJM CPC published 6/6/13
Dx spoilers below! @MedTweetorials
2/n First a PR:
Middle age man w/ PMHx HBV infection p/w chronic fevers and progressive weakness, found to have painful asymmetric mixed motor & sensory distal multiple mononeuropathy and nerve biopsy showing active vasculitis diagnosed with...
Middle age man w/ PMHx HBV infection p/w chronic fevers and progressive weakness, found to have painful asymmetric mixed motor & sensory distal multiple mononeuropathy and nerve biopsy showing active vasculitis diagnosed with...
3/n DDx for mixed motor & sensory multiple mononeuropathy is broad!
▪️Hereditary
▪️Diabetes
▪️Vasculitis
▪️Infections (leprosy, lyme, syphilis, CMV, HIV)
▪️Neoplastic infiltration: (most commonly lymphomatous)
▪️Sarcoid, amyloid
Pt had S4...infiltration of heart & nerves?
▪️Hereditary
▪️Diabetes
▪️Vasculitis
▪️Infections (leprosy, lyme, syphilis, CMV, HIV)
▪️Neoplastic infiltration: (most commonly lymphomatous)
▪️Sarcoid, amyloid
Pt had S4...infiltration of heart & nerves?
4/n
Thyroid Gland ~ Neuropathy overlap
💥 Nerve entrapment 2/2 edematous tissue
💥 Hyperthyroidism
🧬Virus ~ Neuropathy overlap:
HBV: Polyarteritis nodosa
HBV ➡️ HCC ➡️ Paraneoplastic
HCV: mixed cryoglobulinemia
HIV: neuropathic
Thyroid Gland ~ Neuropathy overlap
💥 Nerve entrapment 2/2 edematous tissue
💥 Hyperthyroidism
🧬Virus ~ Neuropathy overlap:
HBV: Polyarteritis nodosa
HBV ➡️ HCC ➡️ Paraneoplastic
HCV: mixed cryoglobulinemia
HIV: neuropathic
5/n
▪️Charcot-Marie-Tooth: a "hereditary motor sensory neuropathy (HMSN)" Associated w/ foot abnormality (pes cavus)
▪️ALS: both UMN + LMN. In a case series: ~23% had sensory abnormalities ≥ 1 nerve. 12.5% ➡️ Dx of electrophysiological polyneuropathy.
ncbi.nlm.nih.gov/pmc/articles/P…
▪️Charcot-Marie-Tooth: a "hereditary motor sensory neuropathy (HMSN)" Associated w/ foot abnormality (pes cavus)
▪️ALS: both UMN + LMN. In a case series: ~23% had sensory abnormalities ≥ 1 nerve. 12.5% ➡️ Dx of electrophysiological polyneuropathy.
ncbi.nlm.nih.gov/pmc/articles/P…
6/n The asymmetric nature of the weakness in this case is notable...
🥃Alcohol, Vitamin (🅱️-12), heavy metals 🪨
All tend to lead to symmetric polyneuropathy
🌟The final diagnosis was...Polyarteritis Nodosa (PAN)!
🥃Alcohol, Vitamin (🅱️-12), heavy metals 🪨
All tend to lead to symmetric polyneuropathy
🌟The final diagnosis was...Polyarteritis Nodosa (PAN)!
7/n
💥 peripheral neuropathy is the presenting symptom of systemic vasculitis in up to 55% of patients
💥 ~1/3 of polyarteritis nodosa cases are attributable to HBV
💥 microscopic polyangiitis can have overlapping features, although MPA is more consistently a/w positive ANCA
💥 peripheral neuropathy is the presenting symptom of systemic vasculitis in up to 55% of patients
💥 ~1/3 of polyarteritis nodosa cases are attributable to HBV
💥 microscopic polyangiitis can have overlapping features, although MPA is more consistently a/w positive ANCA
8/n @TxID_Edu
🤯 IgM anti-HBc Ab, classically an indicator of acute infection, can be present in reactivation & flares of chronic infx
Clues to acute HBV in symptomatic hepatitis:
1⃣ > 1:1000 (high) IgM anti-HBc titers
2⃣ < 0.5 pg/mL or < 10^5 copies/mm (low) HBV DNA levels
🤯 IgM anti-HBc Ab, classically an indicator of acute infection, can be present in reactivation & flares of chronic infx
Clues to acute HBV in symptomatic hepatitis:
1⃣ > 1:1000 (high) IgM anti-HBc titers
2⃣ < 0.5 pg/mL or < 10^5 copies/mm (low) HBV DNA levels
9/9 Back to RLR, #MedTwitter check out this phenomenal @CPSolvers discussion where the CC was scrotal pain.
🤓A cool association:
Rarely PAN can affect the arteries perfusing the testes, and can lead to bilateral non-reproducible testicular pain
clinicalproblemsolving.com/2020/05/14/epi…
🤓A cool association:
Rarely PAN can affect the arteries perfusing the testes, and can lead to bilateral non-reproducible testicular pain
clinicalproblemsolving.com/2020/05/14/epi…
