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Cases from the Wards

Cases from the Wards. Maryland ACP 2015. Disclosures- None. 20 year-old with Buttock Pain and Fever. Case 1. Case Study of A.H. 20 yo white female with no significant pmhx 3 weeks before presentation, AH noted fever, non-bloody diarrhea, & abdominal pain that resolved in 48 hrs

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Cases from the Wards

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  1. Cases from the Wards Maryland ACP 2015

  2. Disclosures- None

  3. 20 year-old with Buttock Pain and Fever Case 1

  4. Case Study of A.H. • 20 yo white female with no significant pmhx • 3 weeks before presentation, AH noted fever, non-bloody diarrhea, & abdominal pain that resolved in 48 hrs • 2 weeks prior to presentation, noted right hip pain that radiated down the back of her right leg. Intermittent fevers • Treated with doxycycline and NSAIDs • Pain worsened, and she was unable to walk

  5. Case Study of A.H. • MRI of hips/bone scan performed 10 days prior to presentation were read as normal • No recent trauma- Fallen off her horse and on her buttock multiple times in the past

  6. Case Study • At time of presentation • Unable to walk • Slept only on her left side in a recliner • Unable to fully extend the right hip • No recent fever • Nl fmhx, social hx, developmental hx, and pmhx. Denied sexual activity

  7. Case Study: PE • Nl vitals • Very uncomfortable- 10/10 pain score • Exam normal but for MSK exam • Tenderness over the right SI joint • Tenderness in right groin and upper thigh • Very limited active right hip flexion with limited internal/external rotation • Position of comfort was hip flexion with external rotation • No signs of enthesitis

  8. What additional labs/diagnostics do you want?

  9. Who would you consult? • Oncology • Infectious Disease • Rheumatology • Ortho • No one- I got this!

  10. Case Study: Labs • Normal CBC except Hemoglobin- 10.8 g/dL • Normal CMP, CK, and Aldolase • Rheumatoid factor and Lyme disease serology- negative • HLA-B27 by flow was not present • Serum C3, C4 and complement function- normal • Antinuclear antibody was positive with a 1:80 titer • No GC with multiple swabs • Cultures of blood were negative • Erythrocyte sedimentation rate- 102 mm/h • C-reactive protein- 6.4 mg/dL

  11. Case Study: Radiology • Review of outside films • Plain film: revealed evidence of widening of right SI joint with irregularity and sclerosis on the iliac side • Bone scan: subtle inc uptake in right SI joint • MRI: abnl signal in right SI joint and adjacent sacrum and iliac. Minimal fluid

  12. Diagnostic Procedures • Culture of stool • CT guided aspiration of right SI joint with culture • Gram stain negative from SI joint aspiration

  13. Helpful Results • Stool and SI joint fluid grew Salmonella enterica serotype Montevideo that was pan-sensitive

  14. The Big Finish • AH later remembers that the day before her GE illness, she had baked cookies for her mother’s birthday with eggs from their farm and …………………… • …………… she ate lots of batter!!!!!!!!!!!

  15. Final Diagnosis: • Salmonella gastroenteritis with hematogenous spread resulting in Salmonella septic sacroilitis

  16. Reacquaint Ourselves with the SI Joint

  17. Joint formed between the auricular surfaces of the sacrum and the ilium • The articular surface of each bone is covered with a thin plate of cartilage in close contact with each other

  18. Sacroiliac Articulation (articulatio sacroiliaca) • Inferior two-thirds: separated by a space containing a synovial fluid permitting free motion • Greatest at birth • Decreases from birth to puberty • In women, mobility increases after puberty to peak around age 25 • During pregnancy, relaxin effects on ligaments increases mobility • Mobility decreases in the 4th and 5th decades and is absent in the elderly

  19. Vascularization of the SI Joint • Peaks in 2nd decade of life and declines after the age of 30 • Originates from the pelvic and paravertebral venous plexus of Batson

  20. Age Distribution in DecadesSalmonella septic sacroilitis Median Age- 16 years old Mean Age- 18.8 years old

  21. Age Distribution of Pyogenic SI • Mean age- 22 years, range 1-71 years1 • 166 cases of confirmed pyogenic SI joint infections in children and adults from 1878-1990 (excluded mycobacteria and brucella) • Mean age: 20 years2 • 177 cases from 1990-1996 in the literature • 1Vyskocil JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint. Case reports and review of the literature. Medicine (Baltimore). May 1991;70(3):188-197. • 2Zimmermann B, 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin Arthritis Rheum. Dec 1996;26(3):592-604.

  22. Symptoms of Salmonella septic sacroilitis

  23. Risk Factors for Salmonella septic sacroilitis

  24. Lack of Risk Factors other than Age • No IVDU • No Sickle Cell Disease • No Corticosteroid Treatment • No SLE • No GU infections

  25. Delay in Diagnosis of Pyogenic SI • Lack of awareness of the entity • Nonspecific presentation of the illness • Posteriorly situated physical findings • Referred pain makes other more common diagnoses seem more likely • Appendicitis • Septic Hip • Lumbar Disc disease • Gordon G, Kabins SA. Pyogenic sacroiliitis. Am J Med. Jul 1980;69(1):50-56.

  26. SI Joint Afflictions Relapsing polychondritis Whipple’s disease Trauma Metastatic lesions or sarcoma Degenerative lesions Osteitis condensans ilii Radiation therapy Immobilization Sarcoid? • Septic Arthritis • Inflammatory disorders like the seronegative spondyloarthropathies • Crystal arthropathies- gout, pseudogout • Rheumatoid arthritis • Familial Mediterranean Fever • Hyperparathyroidism • Behcet’s disease

  27. Delay in treatment of Salmonella SI • > 80% Gram-positives • Staph Aureus by far most common at 70% • 2nd most common- Streptococcal species • 9 % of all cases • 21% of strep cases associated w/ gyn conditions • 6 caused by GBS • 17% Gram-negative infections • Pseudomonas most common- only IVDUs • E. coli- 8 cases • Almost always associated with UTIs • Zimmermann B 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin Arthritis Rheum. 1996;26:592– 604.

  28. 89-year-old with decreased elimination Case 2

  29. Case Study 2 • An 89-year-old woman with untreated stage 0 CLL and a history of stage III colorectal cancer • treated with hemicolectomy and adjuvant capecitabine 3 years prior • Reported feeling “dehydrated,” nauseated, and constipated, with decreased output from her colostomy. • No urine output for 4 days • felt that she had to urinate, “but I can’t.” • Decrease in fluid intake. • Denied fevers, chills, abdominal pain, or loss of appetite. • While waiting to be seen in the emergency department, the patient was finally able to urinate.

  30. PMH • Colon cancer with no evidence of recurrence • Normal postoperative PET three years prior • Normal colonoscopy one year prior • Normal surveillance CT one year prior • Other history • Well controlled hypertension • Well controlled hypothyroidism • Well controlled hyperlipidemia • Chemotherapy-induced neuropathy • Anxiety

  31. Medications • buspirone 5 mg 3 times a day • metoprolol 25 mg twice a day • lisinopril/hydrochlorathiazide 20/25 twice daily • pantoprazole 40 mg once daily • levothyroxine 100 mcg once daily • gabapentin 300 mg twice a day • solifenacin 5 mg once daily (started 10 days prior to her admission) for bladder overactivity • fenofibrate 145 mg nightly

  32. Physical Exam • Appeared non-toxic • Abdomen: • hypoactive bowel sounds and mild diffuse abdominal tenderness • No peritoneal signs • Foley placed with PVR of 50cc

  33. Small Bowel Obstruction

  34. What is causing her SBO?

  35. Do you send her to surgery?

  36. Hospital Course • With cessation of solifenacin and lisinopril/HCTZ and hydration, her constipation, acute renal failure, and feeling of urinary retention resolved • After 4 days, she tolerated a diet, and her colostomy output normalized • After eight months, her creatinine and abdominal CT were normal

  37. Final Diagnosis • Small bowel pseudo-obstruction and the feeling of urinary retention associated with solifenacin, an antimuscarinic

  38. Safety Analysis of SolifenacinRandomized Placebo Controlled Double-Blinded Studies *Trials were 12 weeks and did not utilize an intention to treat analysis ^ Inclusion criteria: men and women aged ≥ 18 years, symptoms of overactive bladder syndrome for ≥ 3 months, average frequency of ≥ 8 voids/24h † Exclusion criteria included significant bladder outlet obstruction, postvoid residual > 200mL, presence of a neurological cause for detrusor muscle overactivity, any medical condition contraindicating the use of antimuscarinic medication, diabetic neuropathy, and use of any drugs with cholinergic or anticholinergic side-effects • Pooled analysis of patients ≥ 65 years old in Chapple6, Cardozo5, and 2 unpublishedstudies2

  39. Int Urogynecol J (2012) 23:983–991 urgency episodes/24 hours micturitions/24 h urge incontinence episodes/24 h

  40. Discussion • Prior to 2008, in 4 randomized trials, only 189 patients of the 1811 who received active drug were > 75 years. • In the four 12-week clinical trials in which 1158 patients were treated with solifenacin 10mg, there were 3 serious intestinal adverse events: fecal impaction, colonic obstruction, and intestinal obstruction. • Patients receiving solifenacin were more likely to experience constipation than those given placebo • 5mg- 5.4% • 10mg- 13.4% • Placebo- 2.9% • In patients who urinated an average of 11.6-12.32 times per 24 hours, efficacy trials showed a mean decrease from baseline of 1.1-1.59 times with placebo as compared to 2.0-2.81 times with solifenacin.

  41. Conclusion • First think drugs • Solifenacin’s risks likely outweigh its benefits • Dearth of clinical data on patients > 75 years of age • Effects of age on the pharmacokinetics • Higher likelihood of bowel pathology in the elderly • Increased risk of solifenacin induced side effects in the pooled analysis of patients ≥ 65 years old • Minor clinical benefit of solifenacin

  42. 55-year-old with right epigastric pain Case 3

  43. April 30- Urgent Care • CC: Right epigastric pain in a 55-year-old • HPI • Lung pain under right breast • Pain improved with rest and sitting up. Almost gone @ rest • Worse with cough • Hurts with deep breathing. • Began 4/19. Left ureteral stent placed on 4/9 • Noted DOE with walking up a flight of stairs • 4/19-4/23, then resolved • Started again 4/28

  44. Case Presentation • 55 year old • Pmhx: • 390 lbs, 6’1’’ BMI: 53 • Cystinuria • HTN • Past Surgical Hx • Recent lithotripsy • Left ureteral stent for obstruction by stones (4/9) • Multiple percutaneous nephrostomy procedures x 10yrs • Medications • Ace-I

  45. Physical Exam • VS • 155/97, p-122, Temp- 99.1, Sat-92% • Nothing else obvious on exam

  46. Labs from 3/24 Labs from 4/30 Na- 141 K- 4.7 Cl- 103 CO2- 30 BUN- 17 Cr- 1.4 Gluc- 97 WBC- 9.3 HCT- 47 Plts- 193 • Na- 136 • K- 5.4 • Cl- 104 • CO2- 24 • BUN- 45 • Cr- 5.1 • Gluc- 97 • Nl LFTs • WBC- 12.5 • HCT- 44.5 • Plts- 166

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