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Thieves’ Market 2013

Thieves’ Market 2013. J. Scott Neumeister MD Associate Professor, General Internal Medicine The Nebraska Medical Center. Back Pain. A 48 year old male presents with a 3 month history of low back pain. His pain started 3 months ago after getting jarred

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Thieves’ Market 2013

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  1. Thieves’ Market 2013 J. Scott Neumeister MD Associate Professor, General Internal Medicine The Nebraska Medical Center

  2. Back Pain A 48 year old male presents with a 3 month history of low back pain.

  3. His pain started 3 months ago after getting jarred while on a roller coaster ride. He has been taking Tramadol and seeing a Chiropractor without any relief. The pain is worsening and he now has trouble walking.

  4. He has not been able to work at his job as electrical contractor for this time period. He has been bruising easily on his arms and legs without defined trauma. He notes his legs have been swollen. Furosemide has not helped reduce the swelling. He has noticed some difficulty passing his urine with rare incontinence.

  5. Married. 3 kids. Electrician. No Tobacco. Rare ETOH. No drugs. PGM had breast cancer Tramadol, Furosemide No allergies Appendectomy years ago.

  6. 98.7 88 16 122/60 Takes 3 people to stand him up strength, reflexes, sensations intact proprioception normal painful with any movement Back tender along vertebrae diffusely Bruising on arms and legs, no other skin abnormalities Edema legs – symmetric, below knees Prostate normal No lymphadenopathy

  7. 14.2 11.7 179 141 105 19 108 41 3.4 27 0.9 9.5 AST/ALT normal AP 217 Bili 1.3 TSP 4.9 Alb 2.9 B12 normal TSH normal

  8. T5, T7 – L5 compression fractures. Some new, some old, some new on old

  9. UA normal (no protein) Sed rate 2 SPEP normal Immunofixation normal Bone Marrow Bx normal

  10. Vitamin D 60 PTH 30 (normal) PTHrp negative Heavy metal screen normal Dexa – T score -2.8 Z score -2.8

  11. Cortisol 28 (< 18) Testosterone 32 (180 – 900)

  12. Urinary cortisol 445 (<60) Salivary gland cortisol elevated X 3 LH, FSH, prolactin, ILGF-1, free T4 normal ACTH 159 (<46)

  13. MRI Sella – No adenoma noted “minimal signal intensity heterogeneity” CT chest – normal CT abdomen – nodular adrenal gland

  14. Petrosal sinus sampling - ACTH 5437

  15. Pituitary exploration – Possible adenomatous tissue resected Path consistent with fibrosis Follow up urine cortisol normal Serum cortisol 11 ACTH 61 (<46) - (repeat MRI sella pending)

  16. ACTH Dependent Cushing’s Disease Petrosal sinus sampling IF adenoma less than 6 mm ? If the side can be localized accurately Cure rates with surgery - 0 – 80% Difficult to prove cure, follow annually Repeat surgery, irradiate, adrenalectomy are future options

  17. Cough A 59 year old Caucasian male has a 5 month history of a non productive cough

  18. He has had progressive SOB. He is having difficulty walking up a flight of stairs. He still carries 80 pound bags at work. He has worked as a forklift operator for the past 4 years. He is exposed to salt dust, feed additive, and fertilizer dust. He has lost 80 pounds by following a gluten free/ high protein diet He took anabolic steroids as a bodybuilder in the 70’s and 80’s

  19. ROS: NO fever chest pain palpitations travel pets hx of heart/lung disease swollen joints edema blood loss

  20. PMH: Solitary Kidney. Rotator cuff surgery. HTN. FM: Dad with unknown type of cancer. SOC: Girlfriend. No tobacco, etoh, drugs All: Bee stings, PCN – anaphylaxis Meds: Symbicort (didn’t help) Hydralazine 25 mg TID Metoprolol 25 mg BID Albuterol MDI Niacin 1 gm BID Cialis 10 mg

  21. 145/91 73 36.1 16 221 lbs 6’2” Neurologic normal Ears normal Eyes – clear, no injection No LN Thyroid Normal Lung: Bilateral Rales No rashes bases No swollen joints Heart normal

  22. 9.4 138 107 41 107 lft’s normal 6.6 250 4 26 3.3 8.9 alb 2.6 UA Large blood baseline Cr. 1.7 Mild protein 50 RBC No WBC No casts O2 sat, EKG, ck, troponin, tsh all normal

  23. echo EF 60% LVH, La mild dilated FEV1 3.65 93% FVC 4.39 91% DLCO 99% CT Bilateral ground glass opacities in a centrilobular distribution

  24. Bronch – No blood, lavage normal Viral panel negative Histo Ag negative

  25. Hemocultneg B12, folate normal Iron 6 Ferritin 84 TIBC 259 LDH normal, Haptoglobin normal DAT IgG +, C3 neg Sed rate 86 crp 5.9 Epo 28 (4-27)

  26. ANA 1:1280 dsDNA + anti-histone + ANCA+ Serine Protease 3 + (assoc with c-anca) Myeloperoxidase AB + (assoc with p-anca) C3 84 (90-180) C4 normal GBM normal cryo, hiv, hep B/C negative Urine protein 500 mg US – atrophic left kidney, normal right kidney mild splenomegaly.

  27. Renal bx – Focal necrotizing glomerulonephritis with mesangial immune deposits “full house” mesangial deposits IgG, IgM, C1q, C3, Kappa, Lambda granular staining Albumin linear staining No IgA staining

  28. Hydralazine induced vasculitis/ Drug induced Lupus Main therapy is cessation of drug however Hydralazine induced disease typically requires therapy Treated with steroids and cyclophosphamide with near resolution of renal function

  29. 10% of patients taking Hydralazine get drug induced Lupus Rare to have renal involvement with drug induced Lupus Rare to have immune complexes in Drug induced vasculitis Typically p-anca+, rare to be c-anca

  30. Weakness A 77 year old Caucasian male notes several months of progressive weakness

  31. When he first presented (6 months ago) he was discovered to have gallstones. His gallbladder was removed and he felt better for a brief period following surgery. He has since lost 35 pounds. He is not eating well. No specific symptoms He has had to have his blood pressure meds stopped or lowered due to low blood pressure He notes episodes of dizziness upon standing

  32. SOB with exertion The weakness is worse in his legs Feels like his feet go “numb” Muscle/joint pain at baseline with his “arthritis”

  33. NO chest pain palpitations vertigo/imbalance diarrhea bladder sx fevers travel

  34. Soc: Trucker/chemical mixer. Married Lives near Kearney, NE 80 pkyrtob No etoh/drugs Fm: Dad died of Leukemia Mom died of ovarian cancer Sister has thyroid disease All: None PMH: Rotator cuff repair, Appy, HTN, GERD

  35. Meds: ASA 81 mg Metoprolol XL 25 mg MVI Omeprazole 40 mg Oxycodone/apap 5/325 (2-4 a day) Biotene Dry mouth rinse Simethicone as needed Spironolactone 25 mg Zolpidem 10 mg Lisinopril 2.5 mg (has been held) Albuterol MDI as needed

  36. 104/63 73 35.6 20 76.9 kg Thyroid enlarged No LN CTA RRR Cranial nerves normal Rhomberg normal 4/5 strength arms 3/5 strength hips 4/5 strength lower leg Diminished sensations lower extremities – light touch Reflexes 1+ patellar, absent ankle

  37. Sats 95% 7.47/22/63 EKG Normal Trop Normal 10.4 4.2 135 N 45 L 36 M 10 Eos 5 Bas 3 31 CXR atelectasis L base CT emphysema. small effusions. splenomegaly ECHO PA pressure 40. trivial valvulopathy. EF 60%

  38. 93 24 55 alb 2.7 protein 6.0 4.2 21 1.4 9 TSH 0.07 (0.4 – 5) CK 5 sed rate 44 crp 18

  39. Free T4 0.3 (0.5 to 1.5) TSI neg TPO Abneg US multiple small nodules favoring benign etiology SPEP neg Immunofixationneg pre-albumin 5.1 (18 -38)

  40. Cortisol 7 (6 – 22) B12, folate normal Iron 23 (low) TIBC 183 Ferritin 442 Vit A 83 (300-1000) Thiamine 70 (70-180) Vit D 26 (30 – 200) Vit E normal

  41. ACTH 11 (0-46) Cortisol 7.1 30min 13 60min 13 Testosterone <10 FSH 4.9 (1.3-19) LH 1.7 (1.3-19) Prolactin 17 (< 13) ILGF 16 (39-184) MRI pituitary – normal. Brain small vessel disease.

  42. Panhypopituitarism ? if due to hypotension peri/post operative for his gallbladder. Placed on steroids, testosterone, thyroid, vitamins A, D, and thiamine He felt better…..but only for a brief period

  43. He presents with ongoing weakness. Now having difficulty standing without a 2-3 person assist Exam significant for 3/5 strength in his major muscle groups (legs worse than arms) He is taking his meds. Repeat lab data indicates a normal T4 CK 5 sed rate 44 crp 18

  44. MRI SPINE C5-5 spinal stenosis. Multilevel neural impingement T spine – mild djd L4-5 neural abutment. Multilevel djd Aldolase 11.9 (1.5-8.1) LP – no oligoclonal bands, cytology neg

  45. EMG (right arm/leg) Proximal myopathy, peripheral neuropathy

  46. Muscle Bx: Intravascular Large B-cell Lymphoma RARE Present with CNS/neuropathy in Caucasians Present with bone marrow findings in Asians 50% 3 year survival

  47. Joint Pain A 25 year old female notes red, swollen joints of her wrists, knees, and ankles

  48. Her joint pain started 3 months ago. It occurred during the first week of her cycle. It has recurred each month in a cyclic fashion. She stopped her birth control pills a few weeks before the first event. She has been on and off OCP’s since she was 16 – started and stopped for no significant medical reason.

  49. She saw a physician who prescribed her steroids. She did not have any problems reaching the summit of Mount Kilimanjaro (Tanzania), however she noticed her fingers blanched at the summit. The finger changes had occurred previously during cold Boston winters Her joint pain keeps recurring and is interfering with her marathon training

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