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.
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 was put 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.
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.
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 .
History : Patient was known case of HT,DM ( on treatment ) . He has complaint of fever since last one month . He came 5 days ago to the hospital with breathing difficuty and decreasing urine out output. For one month he was tretaed at local place with mutples doctors but no response .
To begin with his HB WAS 10GM%, PLT 76K ,TLC 24K. CREAT 5 MG%, ABG 7.36,PCO24,HCO3 22, . His platelets dropped rapidly over 5 days to 1000. LFT normal . ;LDH Normal . Fever still concern. Procalcitonin 20.USG ABDOMEN- B/L CONTRCATED KIDNEYS
Patient alert ,needs NIV, and HD . No response to pitazo and .
Looking to history and course I asked for ESR ,CRP, ANA PROFILE , TOTAL PROTEIN , LDH, FRAGMENTED RBCS , LFT , BLOOD CS, ECHO and repeat USG ABDOMEN.
ONE FINDING WHICH WAS CONSITENT THAT DESPITE ALL THE PROBLEMS – HE WAS NOT HYPOTENSIVE , HE WAS NOT ACIDOTIC AND HIS SOFA SCORE WAS CONSISTENT .
FOLLOWING RESULT CAME – ESR 145, CRP 30, TOTAL PROTEIN 9GM%
ASKED FOR PROTEIN ELECTROPHORESIS – DX CONFIRMED MULTIPLE MYELOMA.
( EXPLANED HIS NORMAL ABG )
PATIENT WENT DAMA DUE TO COST ISSUES.
Last 6 month pain has increased so much that it , it affected her sleep and appetite.
Came to me for diagnostics work up 4 days ago. After analysing all her reports ,findings were – generalised abdominal tenderness, eosinophils 5-6%, weight loss 4 kg.
So one of the most exciting case for me to find out the cause – Case was diffuse tenderness , eosinophilia and raised CRP.
DD WAS – AUTOIMMUNE PERITONITIS, OCCULT TB-( CHRONIC PERITINEAL SEROSITIS), VASCULITIS, GLUTEN INTELORANCE, IBD( CROHNS) AND PRIMARY ADDISSON DISEASE.
INVESTIGATION REVEALED – 6 am cortisol 2 ( VERY LOW), ACTH ( 49-HIGH ).
PATIENT DID MENTION – EXCESSIVE TIREDNESS, FASCIAL PIGMENTATION AND MOOD SWING.
And then miracles happened – 20 mg wysolone – and patient was relived of her pain of 2 years.
Fairly preserved Sort ACTH test shows that patient will need very low dose steroid for life time.
In my visit to her home I found her breathless, coughing continuously ,HR 120, BP 140/90 ( AMLODIPINE 10 MG, MINIPRESS XL(TDS) & OLMIN-H40, SPO2-92% (RA) and BIPAP, RBS WAS VARYING ( 300-450) ON OHA AND LANTUS, ,B/L TENSE PEDAL EDEMA
FOR ASTHMA SHE WAS ADVISED – MEDROL 6MG, FORACORT PUMP, IPRAVENT PUMP, AND BIPAP, DERIPHYLLINE TABS.
SO SHE WAS SO SICLE AT THE TIME OF DISCHARGE, STILL SHE WAS SEND HOME, AND THAT IS REASON CALLED ME KNOW IF I CAN DO ANYTHING OR PATIENT IS DESTINED
THID COURSE ONLY.
My 1 st target was to confirm diagnosis, find the severity of the problem, look for cause and find precipitating factors.
Adv- PFT, CBC, LFT,RFT,URIC ACID , D-DIMER, PRO BNP, ALLRGIC TEST ,IGE,.SPTUTUM EXAMINATION
ALL THESE REPORTS I GOT DONE AT HOME ONLY.
PFT confirmed severe reversible airway obstruction , PEFR 0.60-( CRTICAL RESPIRATORY FAILURE)
ABG- CONSITENT WITH HYPOXIC RESIRATORY FAILURE AND PCO 49- ( VERY HIGH IN ASTHMA AS THEY HAVR LOW PCO2), pH-7.34
SPUTUM POSITIVE FOR FUNGAL HYPHAE – ASPERGILOUS
PRO-BNP 400,URIC ACID 7.5.
ALLERGIC TEST POSTIVE –
IGE HIGH ( 435 IU)
For Asthma- I STOPPED BIPAP AND PUT HER ON HOME OXYGEN THERAPY.
We have started on nebulizer( as patient in not candidate for inhaler or rotacap)-duoline, budicot, foracort and tab wysolone 20 mg.. Tobamist , montigress –LC, ACEBROPHYLLINE & VONAZ (200MG BD).
AS IGE WAS HIGH –I HAVE PUT HER ON SC DOSE OF BOLSTRAN AS PER BODY WEIGHT AND IGE.
HER BP WAS HIGH ON THREE DRUG DUE TO RESPIRATORY DISTRESS. WE CHANGE TO CILINDAPINE 10MG BD, OLMINE H 40 . I COULD STOP HER MINIPRESS XL.
FOR DM –WE HAVE PUT HER LANTUS -3 DOSE AND NOVARAPID AAER PER SCALE. AFTER 7 DAYS –her PEFR rose to 1.25, cough decreased to 50%, could walk and speak.
We started home rehabilitation program for her and after 4 week, her PEFR ROSE 1.85-2.0. COUGH GONE. SUGAR CONTROL AND BP CONTROL.
DX- INTRACTABLE ASTHMA, WITH ASPERGILLOUS INFECTION, UNCONTROLLED DM, AND HYPERTENSION.
NOW I AM WAITING HER PEFR TO IMPROVE TO 2.25 SO I CAN GO FOR BRONCHIAL THROMOPLASTY
The current problem is so severe that she became wheelchair bound . In last two year she was seen by multiple docs at UAE and India. Multiple CT ,and MRI of head and spine, nystagmogram, audiogram , could not diagnose her problems.
She has continuous ringing sensation in both ear , sleep disturbances, vomiting sensation and nystagmus in looking upwards and lateral side. There is history of evening rise fever since last 3 month. No weight loss.
Positive findings in her blood reports – Hb 8.5 gm ( confirm iron deficiency -replacement started). Heavy and prolong menstrual losses.
My 1st approach was to rule out local pathology, for which I took help of ENT & Neurophysician. We did repeat ,MRI brain & cervical spine which was normal . MRI PNS -fluid filled collected in maxillary and ethmoid sinuses.
Audiometry was normal . Nystagmus in upward gaze – ( indicates systemic disease ). So clinical diagnosis was Ataxia with upward gaze without localising signs.
So I needed to look for systemic causes and clue was from Low Hb & sinus involvement . Though the anaemia was of iron deficiency ,but causes of heavy menstrual loss could not be ascertained in view if normal ovary and uterus.
MY 1st clinical impression was RES system involvement . S I examined the patient and found mild splenomegaly with Left Supraclavicular Lymphadenopathy . USG -Abdomen confirmed the abdominal lymphadenopathy with hepatospleenomegaly . Lymph node biopsy confirmed low grade follicular lymphoma. PET -CT confirmed the extensive uptake of hot area in thorax & abdomen. After 1st dose of chemo -patient’s ataxia is gone while sitting and lying.
On literature review I found that lymphoma presenting as nystagmus /ataxia is very rare . Case explained is autoimmune antibody against balance system.
Her CSF,BONE MARROW IS UNREMARKABLE.
She was evaluated for these ailments –HRCT AND CTPA- NORMAL. ECHO TR with RA /RV DILATED ( PASP 54)
OTHER ROUTINE BLOOD REPORTS NORMAL.
SHE IS ON ECOSPRIN, CLOPIDOGREL, AND ROSUVASTATIN AS WELL.
NO SIGNS OF BRONCHOSPASM.
B/L TENSE NON-PITTING EDEMA
B/L PLEURAL EFFUSION –TAPPING –TRANSUDATE .
LAST 15 DAYS HER URINE OUTPUT IC DECREASED TO LESS THAN 400ML
SHE IS HAVING DIARRHEA AT LEAST 5-6 TIMES.
After a careful history and examination what I found that Hypertension and hypothyroidism were detected almost together, edema was non-pitting, she has blackish tongue & cheek discoloration, breathing difficulty seems to be more related to chronic fluid overload rather pulmonary or cardiac. Tachycardia was due high Eltroxin dose ( 100mcg- TSH <0.03 MCG/DL).
As rule of thumb whenever I see hypothyroidism associated hypoadrenalism I would like to rule out. Relative hypoadrenalism get worse if Eltroxin is given without steroid replacement. Other clues were tongue pigmentation, relative low Na(128) and high K 4.5( despite on diuretics, explained abdominal pain and diarrhea.
I asked for anti-microsomal / thyroid antibody (>1200) which was high, ACTH 58(23-48) high, 6 am cortisol 18 ( should have been above 30 in view of high ACTH. Short –SYN ACTH test confirmed relative adrenaline insufficiency.
Telmisartan has a tendency to affect renal perfusion –so it was stopped. amlodipine causes pedal edema so it was stopped.
Tab Hydrocortisone 40 mg started and Eltroxin reduced to 88.5 mcg. In three days time, she lost 4 kg weight, breathing difficulty reduced by >60%, diarrhea stopped. A surprising finding is that she does not need antihypertensive now.
Dx – autoimmune thyroiditis, relative adrenaline insufficiency with secondary hypertension.
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