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Red Medicine MR

Red Medicine MR. Nirav Pavasia. Case. C/C: My legs are in severe pain

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Red Medicine MR

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  1. Red Medicine MR Nirav Pavasia

  2. Case • C/C: My legs are in severe pain • HPI: Pt is a 38 yo BM w/ PMH of HTN, cocaine abuser, presented to the ER w/ swelling and severe pain in both legs. Pt describes pain as sharp and burning, rates 10/10, tender to touch, non-radiating, associated w/ tightness, aggravated by movement and no relieving factors. Reports that the pain has been going on since 1 week but suddenly got worse last night and woke him up from sleep. Pt has not been able to ambulate 2/2 excruciating pain. Pt denies any similar episodes in the past. Pt has noticed subjective fevers and sweats for the past 2-3 days. • Denies any trauma to the LE, recent travel, chest pain, SOB, n/v, dizziness, lightheadedness, abdominal pain, change in bowel or bladder habbits, wt loss or wt gain.

  3. ROS – Otherwise –ve unless stated per HPI • PMH – HTN • PSH – None • FH – HTN, DMII, CAD • SH – smokes 1.5 ppd, >20 yrs; drinks 12pk beer/day, >20 yrs; Snorts cocaine regularly – last use day before admission

  4. VS • Temp: 38.3 • Pulse: 104 • BP: 169/95 • RR: 18 • O2 sat: 97% RA • Allergies – NKDA • Meds – HCTZ

  5. PE • Gen – WN, WD, in mild distress due to severe LE pain • LE – skin hot to touch, shiny, tightness and TTP in bilat LE, strength 3-4/5 due to pain, 4x5” palpable erythematic plaque like lesion in R calf, 2+ peripheral pulses bilat ext, no crepitus noted • HEENT – NC/AT, EOMI, PERRLA, dry oral mucosa, no LADP, no JVD • Chest – CTABL, no R/R/W • CV – tachycardic, RRR, S1S2 nml, no M/R/G • Abd – soft, NT, ND, NABS, no organomegaly • Neurological – AAOx3, CN II-XII intact

  6. Labs • WBC – 24.8 • Hgb – 15 • Platelets – 198 • PT – 14.6 • INR – 1.2 • PTT – 24.8 • Na – 130 • K – 4.4 • Cl – 88 • CO2 – 30 • BUN – 19 • Cr – 1.0 • Gluc – 106 • Ca – 9.6 • CRP – 18 • ESR – 19 • Urine • Cocaine Pos

  7. Any thoughts?

  8. DDx • Cellulitis • DVT • Superficial Thrombophelbitis • Erysipelas • Gas gangrene • Necrotizing Fasciitis

  9. A/P • Cellulitis – bilateral? • Pt started on IV clindamycin, IV vancomycin • blood cx • Get US bilat LE to r/o DVT • X-ray LE, CT LE w/ contrast to r/o gas gangrene and/or necrotizing fasciitis • IVF

  10. Hospital course • Pt continued to spike temperature for next 2 days, highest noted at 38.8 • US LE: -ve for DVT • X-ray, CT LE: wnl, no evidence of soft tissue edema, abscess, or gas noted. Normal limit LE w/o any pathology. No lymphedematous changes or any inflammatory changes were identified in either of the LE. • The erythamatous plaque like lesion in the R calf now beginning to spread in centrifuge fashion towards proximally and appeared in LLE as well around the ankle and toes.

  11. Any thoughts?

  12. Ddx • Henoch Schonlein Purpura (HSP) • Hypersensitivity vasculitis • Wegener Granulomatosis • Churg-Strauss Syndrome (Allergic Granulomatosis) • Polyarteritis nodosa • Buerger Disease (Thromboangiitis Obliterans) • Infective endocarditis • Thrombotic Thrombocytopenic Purpura • Cocaine induced pseudovasculitis • Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

  13. Further work-up • ANA screen – negative w/ <1:40 • CXR, ACE levels to r/o sarcoidosis – CXR unremarkable, ACE levels 59, CT chest – neg for hilar LADP or ILD • HIV Ab – negative • Hepatitis panel – non-reactive • C3 – 151 • C4 – 37 • RPR – non-reactive • TTE – negative for valvular lesions; normal EF; normal heart function • CPK – high at 351 then trended down to 126

  14. Hospital Course • Pt was evaluated by dermatology service and Bx were taken • Pathology report verbal read - neutrophilic infiltration around the small and medium size vessles showing leukocytoclastic vasculitis • ANCA work up – negative • Blood cx – negative • Pt fever controlled w/ tylenol, continued to have severe 10/10 pain in LE, legs were less tight and shiny

  15. Hospital course • Pt was started on solu-medrol 70mg IV per dermatology recs • Over the course of 2-3 days pt’s pain much improved, rated 3-4/10 and erythamatous lesions began to fade away • Vancomycin and Clindamycin stopped as WBC count normalized and pt afebrile for >3 days as well as clinical suspicion less likely for infectious etiology • PT/OT consult placed – pt began to ambulate slowly

  16. Hospital course • Rheumatology consult placed and…

  17. Rheumatology recs - • Cryoglobulin • Human leukocyte elastase • Lactoferrin • Cathespin • Lupus anticoagulant • Beta-2 microglobulin • 3-2 glycoprotein

  18. Hospital course • Pt continued to improve • Pain subsided to 1-2/10 and pt switched to PO steroids • Pt was discharged home and was to follow up as outpt in 2 weeks with rheumatology clinic

  19. Ddx • Cuatneous PAN (CPN) • Hypersensitivity vasculitis • Cocaine induced pseudovasculitis

  20. Thank you

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