Interesting Cases and Updates

 

ANASARCA— Interesting case 1

This 33 yr female was referred to me for generalised anasarca for 2 years. She has gained 50 kg weight and now was not able to do routine activity due to breathlessness on exertion. O/E Pulse 70/min, BP 170/100, SPO2 95%(RA), generalised pitting edema ( from face to toe). She was comfortable in lying position. CXR-B/L blunt CP ANGLE . ECHO -WNL, grade -2,diastolic dysfunction. She was being treated for hypothyroidism (50mcg eltroxin), hypertension ( amlodipine-10 mg), dytor 40 mg tds . Her albumin level was 3.5 gm%.

 

So as suggested by most of you we did send CBC-N,LFT-N,RFT-N, Na118, K 4.2,URINE-R/M,(Albumin nil,-3-4 cells, No RBCs).Albumin 3.5 gm% total protein 6.5gm%. ECHO-N, USG -Normal kidney- B/L Pleural effusion, free fluid in abdominal wall and 3rd spaces. TSH > 100, FREE T4- LOW, Random cortisol low. Antithyroid Antibody positive very high. Anti -TPO antibody positive.

 

Based on above finding our dx was autoimmune thyroiditis with severe hypothyroidism anad hypocortisolism. We 1st gave 100 mg hydrocortisone and 300 MCG eltroxin. Next day we have started on 200mcg eltroxin, wysolone 10mg ,CILINDAPINE, RAMIRIL AND TEORSEMIDE . She was send home and came back after 14 days. She has lost 40 kg water in 14 days. We needed to stop antihypertensive and diruretics. Now she is doing well on 200mcg of eltroxin and 7.5 mg wysolone.

 

Case 2 – Backache?

Case 2 – Backache?

 

This 43 yr female, from affluent class, came to for second opinion 5month ago. She was suffering from bachache since last two month. No fever,no loss of apetite ,no weight loss and pain was localised to lower back. She was seen by neurologist,orthopedics,rheumatologist,spine surgeons & OB&G. CBC,CT & MRI were normal . ESR 35.Reason for my opinoin was non relieving pain by all measures and she was advised ovarian cyst surgery for pain . As I was I was not convinced with small folicular cyst and pain relation I asked to go to other OB&G, where he said this may due to LS joint TB. As pateint has local tenderness. He send patient back to me. She had local tenderness . I got her montoux, which was positive (20*20).  Usg neck abdomen normal. Repeat ESR-40. CRP 32.

 

 I was of the opinion to start AKT. But patient wanted confirmation, so I advised PET-CT, which showed increased uptake in LS Joint, pancreas and small lesion at Right lung apex area. To get bug and culture it I advised to go LS joint biopsy and cs or navigation-MR guided needle aspiration at clevland USA. Patient went to spine surgeon for biposy where he not only advised against biposy but said it is nothing . Got HLADR27, brucella and ANA profile which was negative. He advised patient to go to ID . As patient was from very affluent class well to lots of supersepecialst ,they took opinion from many concerned superspecialist and everyone advised against AKT.

She wasput on NEOCOXIA AND MINOCYCLINE THINKING that it is PID and even PET CT , MONTOUX , ESR AND CRP ALL WERE IGNORED. She GOT SYMPTOMATICALLY BETTER.

After 6 month they came back to me with more sevre pain , fever low grade and incresed CRP ,ESR. This time same ID person advised that she should be given trail.  Repeat HRCT –THORAX ,increased lung  invlovement , medustinal LN positive . Now last 15 day she is on full AKT .

 

Though I persued this patient so much and was so confident for dx which I could see well before time, but was not endorsed by other seniors so treatment got delayed for 6 moth only.

 

CASE 3-SLE - PREGNANCY-POST CESERIAN -PE

The 28 yr Female, known case of SLE, was is remission due to pregnancy. She underwent cesarian,which uneventful . After 48 hr patient became tachypneic, tachycardia, diaphoretic , hypotensive. Oxygen saturation dropped to 85% on RA. How to approach and manage this patient . Was shifted to me 10 litre oxygen, and dopamine drip. 

 

Once patient came to us our clinical diagnosis was moderate to massive Pulmonary embolism. We did ECHO and usg chest which confirmed our diagnosis OF DVT with PE. As patient underwent major surgery thrombolysis was out of question. PE thrombolectomy catheter is not available. We decided to give enoxaparin 0.1 mg /KG BD , NIV support and Noradrenaline. As patient was non acidotic and RV function was good she was more of case of moderate PE. We expected her to get better with regimen. She did bleed in her surgical site for which we had to open it and pack it. She recovered in 7 days. Later we had put her on warf.

 

Lesson-1- Pregnancy with SLE and autoimmune disease must be screened for DVT ANAD APPROPRIATE DVT prevention / treatment PRECAUTION SHOULD BEE TAKEN before and after cesarian.

 

2- moderate PE IN POST OP condition can be managed with thrombolysis with appropriate supportive care and LMWH or conventional heparinisation. They need very close monitoring and hemodynamic management.

 

Case 4 - Celphas Poisoning (Aluminum Phosphide )

24 years, the married female took 4 tablets of celphas.  She went to primary physicians after 2 hours, he did gastric lavage, gave 100ML coconut oil through RT, and send the patient to me as she was hypotensive.  The patient came with, hr-130, BP100/50 ON DOPA AND NORADR, RR 24, SPO2 95% ON RA, Her ABG- ph-7.30, PCO2-24,HCO3-12.  It is total 5 hours since she took celphas.

This is our 15th case who survived after taking such a high dose and despite hypotension. Only key to survival was referral in time and aggressive CRRT. Only treatment which makes difference in outcome is high volume continues renal replacement therapy at a dose of 35 to 40 ml / kg / hour along with other supportive treatment like adrenaline, noradrenaline, and mgso4. CRRT helps in correcting acidosis, maintaining homeostasis and avoid fluid overload. Most of the time patient needs 36 to 48 hrs of CRRT, and after that most of the patients recover.

What I have found with time that starting CRRT within 2 hours of taking the drug saves most of the patients. That means early referral for doing high volume CRRT can salvage most of the patient.

 

Pain abdomen

38 year ,Male was referred to me for evaluation of pain in abdomen since 1month. He has postprandial heaviness since last three month . For pain abdomen he was seen and evaluated since last one month at different hospitals. He was admitted for this where his Upper G I Scopy ,biopsy , H pylori test were normal . CECT abdomen normal .Complete blood profile was done multiple times. PosItive reports were HB 8.9 GM%, ESR 35. Rest of the blood ,urine ,stool reports are normal. Seen by more experts and they advised colonoscopy and bone marrow examination. Then he came to me for further diagnosis as cause is yet to be found. 

So my approach for this patient was pain abdomen ,without signs of localisation with anaemia without blood loss. Further evaluation I found ,Serum Iron normal, TIBC low, Ferritin Normal, ESR 40, CRP 20, Absolute reticulocyte 7.5%, Total Bilirubin 1.8, ( Indirect 0.9),LDH 340. 

To further narrow it down we were now having additional finding of low TIBC

This lead to DD Of , Chronic lead toxicity , Anaemia of chronic disease , haemoglobinopathy , and other chronic haemolytic anaemic.

Lab results showed -Serum lead 73 MCG /DL ( very high)

We got Cap DMSA ( Succimer ) imported and has started the treatment today.

Addition finding in this patient is he is taking AYURVEDIC treatment for infertility ( decreased motility ).

Blue gum line -Photo attached.