MR with Ryan and Dr. Kanter: Hypopituitarism and sellar mass

An elderly man with a hx of HTN, HLD who presented to clinic with decreased vision and hypogonadism – MRI demonstrated a 3 cm sellar mass compressing the optic chiasm.  He underwent transsphenoidal resection, which was complicated by hypopituitarism necessitating hormone replacement with levothyroxine, hydrocortisone, and testosterone.
 
DDx for visual field cut -> pituitary adenoma, sellar mass, glaucoma

DDx for sellar mass -> pituitary adenoma, prolactinoma, brain metastases, meningioma/craniopharyngioma, granulomatous disease (sarcoid, TB)

Any sellar mass that causes visual field deficits

Macradenoma vs. Microadenoma – Microadenomas should not cause visual symptoms – and are defined as < 1 cm

A common/serious complication of transphenoidal resection is a CSF leak

TSH will NOT be accurate in pituitary adenoma – you have to test the free T4 as well to determine hyperthyroid state

Friday MR with Justin: Scurvy!

A middle aged woman w/ PMHx Bipolar, HLD, and hypothyroidism who p/w syncope in s/o 2-3 months of LE ecchymoses/petechiae, admitted for syncope, anemia, and petechial rash ultimately diagnosed with scurvy.

 

Key Learning Points

-Vitamin C deficiency results in impaired collagen synthesis – typical pathologic manifestations occur in collagen-containing tissues/organs: skin, cartilage, dentin, osteoid, and capillary blood vessels – scurvy may present with gum bleeding, petechiae or ecchymoses

-The skin findings may initially resemble a vasculitis!

-Treatment is vitamin C supplementation – many of the constitutional symptoms improve within 24 hours – bruising and gingival bleeding resolve within a few weeks

Thursday NF Interesting Case with Sonia and Dr. Robbins : Afib

 

An eldely man with a hx of hypothyroidism, recent L TKR and a hx of DVT 1 year prior who was called to come to the ED for a heart rate in the 130s found to be in new afib.

 

Key Learning Points

*Don’t treat subclinical hypothyroidism unless T4 is > 10 or thyroid antibody is +; the reason for treating subclinical hypothyroidism is risk of progressing to an overt hypothyroid state

*IV metop vs. PO Metop

-Per Kaiser Guidelines – oral beta blocker therapy is preferred over IV therapy in the setting of acute MI; oral administration should be initiated within the first 24 hours for MI patients who do not have any of the following (a) heart failure, (b) low output state, (c) increased risk for cardiogenic shock, or (d) other relative contraindications (PR > 240 msec, 2nd or 3rd degree heart block, active asthma or reactive airway disease).   Early aggressive IV beta blockade can pose a net hazard in hemodynamically unstable patients.

*Number to transfuse in setting of ACS?

-The optimal transfusion threshold in the setting of ACS remains unresolved.  In general transfuse when the Hgb is < 8 g/dL and consider transfusion when the Hgb is between 8 and 10 g/dL.  Pilot trial of 110 patients with ACS demonstrated that a liberal transfusion strategy to raise the Hgb >/= 10 was associated with greater survival at 30 days

Wednesday: MR with Alice and Dr. Harry Hollander: Leptospirosis

A middle aged man with fever, bone pain who presents after travel with thrombocytopenia, transaminitis, and AKI ultimately diagnosed with Leptospirosis.

*How do I factor in prophylaxis in a returning traveler?– know that malaria has A LOT of resistance – you need to know if the patient received appropriate prophylaxis for Falciparum in the region – Malarone (atovaquone and proguanil) is generally good for malaria prophylaxis.  The Yellow Fever is a good vaccine

*Know the DDx for fever in a returning traveler: Malaria, Dengue, Chikungunya, Rickettsia, Scrub Typhus, Leptospirosis, Influenza, and Acute HIV

*This case was a very classic presentation for leptospirosis known as Weil’s disease-> liver damage (causing jaundice), AKI (tends to be an interstitial nephritis); and bleeding

*Most ricketssial disease have a dramatic response to doxycycline – also the drug of choice for leptospirosis if the patient does not have meningeal disease

*Geosentinel is a global surveillance network of travel medicine clinics that collect data from ill international travels.

http://www.istm.org/geosentinel

Tuesday MR with Big Lenie and Dr. Lewis: Neuromyelitis optica

A middle aged woman with a hx of severe bilateral glaucoma (legally blind), breast CA in remission who presented with acute proximal lower extremity weakness and subacute dysphagia admitted for statin-induced myositis due to elevated CK, eventually requiring intubation due to difficulty maintaining secretions, and found to have positive AQP4 Ab confirming the diagnosis of neuromyelitis optica.

  • NMO is an inflammatory CNS disorder characterized by severe, immune-mediated demyelination and axonal damage mainly affecting the optic nerves, spinal cord, brain and brainstem. It is distinguished from MS by the presence of AQP4 antibody.
  • Its incidence is 10 times higher in women than in men and more common in people of Asian, Hispanic, and African descent. Median age of onset is 32-41 years.
  • Main clinical features include optic neuritis, acute transverse myelitis, area postrema syndrome.
  • Evaluate with brain and spinal cord MRI, AQP4 Ab status, CSF analysis
  • Diagnosis: Pt has at least one core clinical characteristic; enhancements on brain and spinal cord MRI; positive AQP4 IgG serum (and often CSF) autoantibody status; and exclusion of alternative diagnoses.
  • Treatment: high dose IV methylprednisolone, plasma exchange, and immunosuppression treatment long-term disability and mortality rates are high

Monday MR with Melissa Itsara: GNR bacteremia

 

A middle aged man with stage IV HCC of unknown etiology who presented 2 weeks after biliary stent placement with confusion found to have E. Coli bacteremia.

 

**Learning point for Gram-negative bacteremia

-Treat presumptively with Zosyn – consider 2nd gram negative agent if: immunocompromised; high risk for P. aeruginosa, or unit antibiogram shows drug resistance > 20-25% for GNR pathogens

Risk factors for P. aeruginosa

-Current hospitalization or admission to an intensive care unit

-Recent P. aeruginosa infection

-Recent hospitalization

-HD

-Admission from along-term care facility

-Recent IV abx

-Recent chemo

-Immunosuppression

 

MR with Shawn Tate + Kleckner: Large Granular Lymphocyte Leukemia

A middle aged man with hx of DM2, BPH, multiple recent infections, who presented with Neutropenic fever with ANC of 0 and cellulitis of Left foot.  After multiple hospitalizations was diagnosed with Large Granular Lymphocyte Leukemia (LGL Leukemia).

Teaching points:
– Heme/Onc cases in general are often difficult due to our exposure and the rarity of cares.
– LGL Leukemia is rare, estimated to be 1 in 10 million in US
– Must differentiate this condition from reactive LGL expansions and chronic lymphomatous conditions, as well as chronic and aggressive NK cell leukemias.
– It is thought that autoimmunity plays a central role in its development
Associated with infections (EBV, CMV) as well as RA, Schogren’s and other autoimmune conditions.  40% of cases are associated with RA or an autoimmune cytopenia (pure red cell aplasia, autoimmune hemolytic anemia, ITP.
– Diagnosis is clinical with undefined neutropenia, confirmed with bone marrow biopsy with increased number of LGLs (normal 200-400 micro/L).
– Treatment is primarily immune suppression with MTX, cyclophosphamide, Cyclosporine, +/- steroids. (this patient also received Neupogen with good response)
– Good prognosis, 85% survival at 4 years