Thread by @RosenelliEM

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

July 15th Day 93: clinicalproblemsolving.com/morning-report…

Chat recap of the #ClinicalPearls #VirtualMorningReport

Featuring: @sargsyanz @StephVSherman @tonlajr @AdamTapley
Teaching points overview by @sukritibanthiya

Before we start, if you didn't check out @_HarryPaul_ twitter thread from last wk, 👉👉

https://twitter.com/_harrypaul_/status/1283407283402178561?s=21

Now the initial PR:

A 60 y/o M w/ PMH of relapsing MS dx (last flare 4 yrs ago) p/w unsteadiness, trouble focusing & weightloss was tx for MS flare w/o improvement

"difficulty focusing on objects" --> interesting

maybe he has diplopia, Check out this flow chart for this "blurry" topic

Is this JC virus reactivation with PML?natalizumab and some of the new oral agents can cause: iomcworld.org/open-access/na…

He was treated for an MS exacerbation, what does that entail? ncbi.nlm.nih.gov/pmc/articles/P…

MS can cause lesions in temporal lobe for example

Unusual ocular motor findings in multiple sclerosis
pubmed.ncbi.nlm.nih.gov/16466746/

Ocular findings in MS from prior article: such as bilateral third nerve palsy, opsoclonus, Horner's syndrome and one-and-a-half syndrome (horizontal movement disorders of the eyeballs, )

As for his unsteadiness, we would definitely tease out whether it is a visual, inner ear, cerebellum, or proprioception problem peripherally

Is this his MS or there could be something totally unrelated. An abscess, another primary tumor in the brain etc

Could his optic symptoms be Uhthoff phenomenon in MS? ncbi.nlm.nih.gov/books/NBK47024…

It is induced by an increase in body temperature resulting in“marked deterioration of visual acuity during physical exercise and exhausting”

Another cool phenomenon mentioned by @sargsyanz was Recrudescence of Deficits After Stroke

it occurs approx 4 yrs after the index stroke & is characterized by mild worsening of poststroke deficits that usually resolve within 1 day.

Recrudescence.....Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use are important precipitants; ncbi.nlm.nih.gov/pmc/articles/P…

Now back to which MS medication he is on as there are many side effects. He is on Rebif which is IFN-beta

Interferon B s/e flu-like symptoms, fatigue, depression, increased spasticity, transaminitis, rare autoimmune hepatitis, and injection-site reactions

IFN can kill lymphocytes, make your hair fall, cause flu-like symptoms and psychiatric problems

Fingolimod (Gilenya) s/e Transaminitis, lymphopenia, increased risk of serious herpes inf, HTN, bradycardia (usually only with the first dose), macular edema, basal cell carcinoma, PML

The risk of PML w/ fingolimod in the absence of prior natalizumab tx is 🔽low. 0.069/1,000 pts

It would be hard to attribute this just to MS flare alone given that he was just treated with steroids

What about his gait disorder? a tweetorial on gait disorders,

https://twitter.com/pearlsneurology/status/1280454561350602754?s=21

Physical exam shows supraclavicular lymph node otherwise known as virchows node and makes us worried for cancer including lung/GI cancer, ncbi.nlm.nih.gov/pmc/articles/P…

Is this a Paraneoplastic process leading to opsoclonus?

More on Virchows node: Remember that metastasis to the supraclavicular lymph node indicates advanced stage 4 disease.

Although Virchow's node is typically enlarged in gastric cancer, it can also be seen in lymphoma, breast, oesophageal, pelvic and testicular cancers

Is this a paraneoplastic process leading to opsoclonus?

We are worried about a process in cerebellum especially with relatively normal eye exam

Hmmm. PML generally affects posterior lobes (occipital/parietal) & occipital lobe involvement might explain some of weird vision sxms

His CEA was 1.54. guidelines do not recommend measuring tumor markers but we always do. A review of Tumor markers in clinical practice if you are interested. ncbi.nlm.nih.gov/pmc/articles/P…

Ct scan shows a mass between the duodenum and pancreas with liver mets.

Final Dx: Stage 4 pancreatic cancer w/ paraneoplastic syndrome (PNS)

ncbi.nlm.nih.gov/pmc/articles/P…
PNS is est to occur in 0.01-8 % of cancer pts, w/ 🔼incidence in those w/ small cell lung CA, GYN tumours or hematological dz. Paraneoplastic cerebellar degeneration (PCD) is the MC PNS

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@Sharminzi @ArsalanMedEd @ecvasti @JonathanRyderMD @RezidentMD @GurleyGuy @appyjumpindaze @justalisongrace @DavidTHLam @BethGay45 @BrandonKinneman @rongejman @BryanCUlrich @victorekuta @danaamara1 @NishaSunkuMD @pri_athavale @BhavyaVarma12 @sargsyanz @StephVSherman

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I need to start tagging @cjchiu so he can get some spaced repetition in as well. If you missed his recent episode on @MedTwitThisWeek here you go! We chat about #VMR

https://twitter.com/cjchiu/status/1284170225118621697?s=21

https://t.co/Hnew3IrK6I