Interactive Case Presentation

Doug Kutz MD

Past Medical History58 yo male

Adult onset DM – on Insulin for 18 yrs. Last HBA1C 10.2%, Mild proteinuria and CRI (30/1.7), Macrovascular disease

HTN w/ dias dysfunction

COPD – FEV1=1.0 liter/FVC=2.1 liter (little response to B-agonists)

ASCVD – Heart Cath ‘03: Occluded RCA, L with 40% distal Dz, EF 45%

Paroxysmal AFIB – Clopridogel instead of coumadin due to pt. pref

Multiple CVA’s (L cerebellar, R pontine, L caudate)

Prostate CA – s/p prostatectomy age 49

Dyslipidemia

80+ pack year Tobacco Abuse (Ongoing)

Depression/PTSD – intolerant of anything but MAOI Rx and Clonazepam

“Mononucleolis” with hepatitis while serving in Vietnam

Albuterol 2.5mg unit dose via nebulizer QID

Clopidogrel 75mg QD

Clonazepam 1mg TID

Furosemide 120mg po BID

NPH and Lispro Insulin

Metoprolol 25mg po bid

Pantorazole 40mg QD

Spironolactone 25mg QD

KCL 40meq po BID

Prednisone 10mg po QD

Phenelzine 30mg po BID

Medications

Family History

Mother died age 45 of Uterine CA

Father died age 76 sudden death

Brother died 67 lung CA and COPD

3 Healthy children ages 24 - 36

Admission 12/04CC: Lightheaded and weakHPI: Progressive nausea, some emesis, weakness, and chills. Not using his insulin or taking his meds for 5 days

Exam:Vitals Afeb, 148/82 supine, 108 irreg, 22, P.O. 96% (ra)

HEENT anicteric slcera, dry mm, neck “thick” no obvious jvd

Lungs diffusely diminished breath sounds

CV distant, irreg irreg, no murmur, no rubs

Abdm soft, nontender, nabs

Ext trace edema both ankles

Skin no jaundice or rashes

CNS nonfocal but slightly confused

Labs 12/04

WBC 15.2k, H/H 9.0/26.9, Plt 293kBun/cr 2.9/63 Nml lytesGlucose 390, Slight pos serum ketonesAst 6098, Alt 1601, Alb 2.8, Alk 386, Bili 0.9, Nh3 51Coags nmlTroponin I 1.94ECG: AFIB w/RVR, LVH, nonspecific ST

Imaging/Other Studies 12/04

CT chest: COPD and pericardial effusion

U/S Abdm: nml liver and GB, no masses

Echocardiogram: Large pericardial effusion without tamponade, LVH with diastolic relaxation abnormality

RN: “He is becoming hypotensive”

Drug Interactions: Phenelzine

5-HT agonists

Buproprion, SSRI, mirtazapine

Alpha 2 agonists

Decongestants

Dextromethorphan

Ginseng

Hydralazine

Most sedatives

Linezolid (14 days)

Licorice

Metoclopramide

Promethazine

SAMe

Sulfonylurea

Sympathomimetics

Trazodone

Hospital Course

Aggressively rehydrated

Oliguria and Azotemia resolved after 3 days

Liver function normalized over 3-4 days

Hepatitis serology negative

AFIB did not recur, not a candidate for anticoagulation

Discharge Diagnoses

Severe dehydration due to severe hyperglycemia/medication noncompliance and possible viral GEAcute Tubular NecrosisIschemic HepatitisCardiac “Enzyme Leak” Pericardial Effusion, Incidental/? viralParoxysmal AFIB

Heart disease and Hepatic dysfunction

Hepatic congestionTypically due to exacerbation of chronic CHFLiver enlarged and firm on examModest elevations in ALT, AST, LDH, GGT and sometimes alk phos, total bili, and slight decrease in albuminMild transient jaundice can occurChronic congestion can lead to “cardiac cirrhosis” with fibrosis of liver on biopsy

Cardiogenic Ischemic HepatitisMore acute and severe fall in cardiac output

(such as with an acute MI or Severe CHF)

Enzyme levels often >10x normal

Coagulopathy and Functional renal impairment can be associated

No specific marker for Dx, but typically the transaminases drop >50% in first 72hrs of onset

Outpatient Visit 3/05Dyspnea and pallor, cough.“Considering Hospice”Exam:

Vitals 110/76, 68 reg, Afeb, 22, Wt. up 4# in 1month, pulse ox 93% on room airHEENT dry mm, JVP not visibleLungs: Diminished diffusely, BS absent in right lower ½ w/ dullnessCV: RRR distant, no murmurABDM: NABS, NT, SoftExt: slight increase edema (now 1+)

Outpatient Labs 3/05

WBC 9.3k, H/H 10/34.3, Plt 220

BS 248, Bun/Cr 27/1.3, Nml lytes

Lfts nml except alk 346

TSH 1.70

BNP 467 (nml)

EKG unchanged

Outpatient Thoracentesis 3/05

Red Hazy fluid with many RBC’s

500 nuc cells (4% seg, 22% lymphs, 74% mono’s)

Glucose 238

LDH 82

Protein 1.4 (serum 7.7)

GS + Cx neg

Cytology neg

Outpatient Imaging 3/05

Echocardiogram LVH with no wall motion abnormalities, nearly resolved pericardial effusion.

Admission 4/4/05

CC:Worsening edema, dyspnea and falls

HPI: Despite increasing doses of furosemide, fluid build-up in legs has extended up to chest wall, now distended and bloated abdomen, weight is up 30#. Positive orthop and PND.

Dyspnea continues and is now associated with a cough. Cough is associated with dizziness and lightheadedness. Cough produces yellow sputum 1-2 tbsp per day.

Fell yesterday after a coughing spell and hit his R orbit; now has a “black eye”.

Physical Exam 4/05Vitals: 156/97, 94, 22, 97.8 Wt up 24# from 12/04 Pulse Ox: 90% RA, 94% on 2L NC

HEENT: New circular ecchymosis R orbit, R scleral hemorrage, JVP not visible due to habitus and edema

Lungs: Absent R base to ½ way up, w/ dullness to percussion, BS otherwise diminished diffusely, no wheeze

CV: Irr Irr w/no murmur, distant, no gallups or rubs

Abdm: Distended with no localized tenderness, NABS, prominent liver, no splenomegaly, ? Shifting dullness, pitting up to costal margins

Ext: 3+ pitting edema bilaterally, pos sacral edema

Initial Laboratory Data 4/05

Heme: Wbc 11.2, H/H 10.3/32.3, Plt 295Renal/Lytes: Bun/Cr 36/1.3, Gluc 131, Ca 9.2, Na 141, K 4.8, Mg 2.3Hepatic:Alt/Ast 40/52, AlkP 368, Alb 3.9, Ammonia 26Coags: nmlCardiac: Enz neg, BNP 2800Other: D-dimer 3000, U/A 2+ prot

Imaging 4/05

CXR: R effusion, mild PVC

CT chest: No PE, R pleural eff, some obstructive changes

Head CT: no change

U/S abdm: normal except ascites

Echo: Nml wall motion, LVH w/ dias dysfunction, trace effusion

Fluid Studies 4/05

Pleural Fluid: almost identical to outpatientAscitic Fluid:

Yellow, clear, moderate rbc’s500 nuc cells (20% segs, 15% lymphs, 61% mono’s)

Glucose 177Amylase 20Alb 1.9 (serum 3.9) (s:a gradient 2.05)GS and Cx neg

Diuresed 30#

JVP now visible to 10cm

“A Diagnostic Study was Obtained”

“Doctor I have to get out of here !”

Heart Cath 4/05

Arterial press 139/86LV end-dias pressure 29mmHg (3-12)Pulm arterial pressure 51/25 (15-30/4-12) Wedge pressure 34 (2-10)Kussmaul’s sign noted on right atrial pressure trace, mean pressure RA 26 (2-8)Equalization of LV and RV dias press, as well as LV and RA dias pressures

Tissue Diagnosis:

Fibrotic Pericardium, up to 5mm thick.

Pericarditis

Can present in 4 ways:Acute pericarditis

Incidental effusion

Tamponade

Constriction

Acute Pericarditis85-90% idiopathic, 1-4% viralRemainder of cases are post MI, other infx, AAA, trauma, neoplastic, post surgical or XRT, uremic, connective tissue disease or drug inducedClassic ECG changes: diffuse ST elevationPericardial rub pathognomonic (85% develop)Pericardiocentesis indicated for tamponade, or if strong suspicion of bacterial infx or neoplasmSerologic studies not very helpful (<10% dx)“Troponin Leak” occurs in 35-50%

Tamponade

Occurs in 15% idiopathic, but up to 60% with Tb, bacterial or neoplastic etiology

Presents with “Beck’s triad”• Hypotension

• Quiet heart sounds

• Increased Jugular venous pressure

Can also note compensatory tachycardia and pulsus paradoxus (fall in SBP >10 during insp)

Constrictive Pericarditis

Chronic fibrous and/or calcific thickening of the pericardium that leads to abnormaly elevated diastolic filling pressures

Most commonly idiopathic after acute or sub acute pericarditis (Tb still most common in undeveloped countries)

Post cardiac surgery and radiation therapy becoming more common

Constrictive Pericarditis…..

Clinical findings:Pulsatile hepatomegaly

Pericardial knock (early diastole)

Kussmaul’s Sign: JVP rises (or at least fails to fall) during inspiration, due to separation of the cardiac pressures from the thoracic pressure changes in respiration

Constrictive Pericarditis…..Differential Diagnosis

Other causes of right heart failure• Restrictive Cardiomyopathy• PE or Pulm HTN• Right ventricular infarction• Mitral stenosis or Tricuspid Disease

Cirrhosis or Hepatic Vein ThrombosisAcute Renal Failure or Nephrotic syndromeSVC obstruction or Lymph obstructionMyxedemaDrug Induced (Ca channel, minoxidil, steroids, “glitazones”, NSAIDs,)

Constrictive Pericarditis…..Diagnosis

Unfortunately clinical findings not very specific

Key echo findings are that of a thickened pericardium, a septal “bounce”, inspiratory decrease in pulmonary venous flow, and normal relaxation indices.

MRI is 88% sens, 100% specific using same criteria above

Cath findings that are most specific are equalization of RV and LV end dias pressures.

No widely accepted “gold standard”

Constrictive Pericarditis….

Treatment: PericardectomyUse caution with diureses pre-op

1 month follow up