Thread by @RosenelliEM

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

Chat recap #ClinicalPearls #VirtualMorningReport

June 24th Day 80 clinicalproblemsolving.com/morning-report…

Case Overview @haematognomist

Let's start with a Problem Representation:

A 6o y/o F presents with 10 yrs of SOB, recent falls the last few months, increasing fatigue, constipation (1 BM every 8 days), and new-onset AMS found to have pancytopenia, 🔽Na, 🔽Glu, 🔽 Free T4, 🔽cortisol

From the get-go: Gait difficulties for 7 days, AMS, constipation

Enter MIST pneumonic for AMS

Hypercalcemia links constipation and AMS but Hyper CA doesn't explan dyspnea

she will have polyuria w/her hypercalcemia

ncbi.nlm.nih.gov/books/NBK27912…

Could her anemia be from Bone marrow hypoplasia d/t pesticide exposure given where she lives and occupation?

Pesticide exposure is associated with lymphoma, leukemia, and a Parkinson’s like disease
scielo.br/scielo.php?scr…

with the constipation & patient location, what about Chagas disease.

Another common manifestation of Chagas disease in the gastrointestinal tract is chagasic megacolon. Chronic constipation is the main symptom related to megacolon

ncbi.nlm.nih.gov/pmc/articles/P….

Something else to think of are endemic mycosis, the endemic mycosis of choice would be Paracoccidioidomycosis since she is from Brazil, cdc.gov/fungal/disease…

Cardiac involvement could explain the dyspnea- Chagas can cause heart block

Chagas can take decades to cause these kinds of manifestations

Usually very slow, asymptomatic for a long time (like 20 years I think), ncbi.nlm.nih.gov/pmc/articles/P…

An example of an acute infection with Chagas is a chagoma

A review on the treatment of Chagas ncbi.nlm.nih.gov/pmc/articles/P…

Cardiomyopathy can cause LV clots & emboli. Decomp CHF can cause delirium & Arrhythmias

Could this BM issue be from a GATA2 mutation predisposing to mycobacterium, possibly alveolar proteinosis ncbi.nlm.nih.gov/pmc/articles/P…

would also consider Trichinellosis and TB thinking about infectious causes, ncbi.nlm.nih.gov/pmc/articles/P…

A little hypothermic, constipation, hyporeflexia making us think about hypothyroidism

hypothyroidism presents with delayed relaxation on reflex testing

Hypothyroid can cause hyponatremia/ and anemia

Chronic lead toxicity, basophilic stippling on peripheral smear

Does she have a Queen Anne sign? pubmed.ncbi.nlm.nih.gov/17551609/

Looks like Metabolic is the winner of the MIST mnemonic

A fav CP Solvers schema, hyponatremia , we need serum osm, urine osm and nahttps://images.app.goo.gl/aZWi5KE5EV3Je5d17

TSH is relatively given her low free T4

This can also cause hyponatremia and the hypoNa can cause the AMS

Could this be a pituitary process?

Central hypo due to infectious? infiltrative? invasion? or infarction?

We need a cortisol level!

Seems like pan-hypopit could be at play, very interesting w/ normal brain imaging, although should do dedicated pituitary MRI

As a regular MRI doesnt r/o a Pituitary lesion

Need to remember not to correct hyponatremia too quickly to prevent demyelination in CNS, no more than 10-12meq/24hrs

Also wonder how the bone marrow hypoplasia was diagnosed & when. If an infiltrative disorder could be effecting the marrow too

Is this lung nodule related?

If we are going to give thyroid, we will have to also give steroids also at first, ncbi.nlm.nih.gov/pmc/articles/P…

thyroid replace revs up metabolism, causes drop in cortisol

you can get acute MI if you replace thyroid too quickly

Next step: random cortisol - should be 🔼if 🔽then do a STIM test

If is this is a central lesion, you could see a normal STIM test if you give ACTH in the early phase because the adrenal gland can respond. Later, you get atrophy of the adrenal gland & can see a blunted response

If there is an infiltrative disease (amyloid, infection, etc) that unifies bone marrow and pituitary

Good review on “Endocrine Disruptor Pesticides” ncbi.nlm.nih.gov/pmc/articles/P…

If this is TB, could be miliary, if she has pancyto, infiltration of adrenals would cause electrolyte abn

Multiple pivot points in this case but this looks like like panhypopit. statpearls.com/kb/viewarticle…

Final dx: Sheehans Syndrome, statpearls.com/kb/viewarticle…

It can present acutely or chronically, ncbi.nlm.nih.gov/pmc/articles/P…

An empty sella is seen in 70% & a partially empty sella in 30%

It is generally diagnosed several years postpartum; therefore, it has been recognized as a chronic condition. Here is a case w/ acute manifestations ncbi.nlm.nih.gov/pmc/articles/P…

Usually found w/ agalactorrhea, ncbi.nlm.nih.gov/pmc/articles/P…

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