Theodore Woodward, Nobel prize Dr. Peter Switakowski, MD · 2017-09-14 · Case #2: JG • Went to Sunnybrook 4 days later with significantly increased back pain and discharged home

“When you hear hoofbeats, think of horses, not zebras”

‐Theodore Woodward, Nobel prize

Dr. Peter Switakowski, MD

Disclosure

• None

Objectives

• Discuss clinical cases

• Make you second guess that patient you sent home last night

• Remember that common things are still common

Case #1: CG

• 21 yo healthy woman referred by optometrist

• 1 day left eye floater starting in periphery

• Then central causing blurred vision and pain

• 20/30 OU

• Right eye normal

• Left eye unable to see fundus

Case #1: CG

• Diagnosis?

Case #1: CG

• Next day seen in Eye clinic • Uveitis, small retinal tear

• Bulging retinal veins

• Grew up on Argentina farm, lots of dogs and puppies

• Currently owns a kitten

Case #1: CG

• +ve toxocara serology (ocular larva migrans)• ‐ve syphilis and toxoplasmosis

• Treated with albendazole and prednisone

• Bulging retinal veins injected

• Vitrectomy• During surgery parasitic cysts noted, vitreous hemorrhage

• Permanent vision loss: can only see shapes and colours

Case #1: CG

• 7 months later returns to ER

• 4 days blurred vision left eye with shadows and floaters• on exam light perception only, uveitis

• Treated with prednisone and albendazole

Toxocariasis

• Roundworm from dogs and cats (larva migrans)• Most commonly from puppies 1‐2 months old (80% prevalence)

• Fecal oral transmission, rarely from uncooked meat• Geophagia and contact with puppies is risk

• 14% of US population has antibodies to Toxocara

• Predilection for kids and young adults

• Prevention is key (handwashing, deworming puppies)

Toxocariasis

• Migrating larva to:• Eyes, liver, lungs, CNS (eosinophilic meningoencephalitis)

• Most are asymptomatic• depends on number, and degree of immune and inflammatory response

• Visceral presents with:• Fever, fatigue, cough/pneumonia, wheeze, hives, abdominal pain/hepatitis, myocarditis, seizure

Ocular Toxocariasis

• Presents with:• Painful vision loss, floaters, photophobia, red eye, monocular leukocoria

• Posterior uveitis, retina detachment, chorioretinitis

• Granulomatous disease of peripheral (50%) or central (25%) retina, endophthalmitis (25%)

• Study showed that misdiagnosed retinoblastoma was 26% toxo

• 1% of uveitis in a study had toxocariasis

Toxocariasis

• ELISA test for antigens if high suspicion• may be negative if ocular only, so test eye fluid

• Suspicion based on: exposure, eosinophilia, high IgE

• Similar to other migrating larvae• baylisascaris (also ocular), strongyloides, paragonimus

Toxocariasis

• Treated with albendazole 400mg BID, +/‐ systemic steroids

• Surgery – laser, and/or vitrectomy to prevent further damage• Consider for persistent opacification, bleed, detachment, epiretinal membranes

• Most patients post surgery (87% in one study) have vision worse than 20/400

Ocular Toxocariasis – take home points

• Floaters still most likely benign

• Ensure retinal exam

• Remember PAINFUL FLOATERS could be toxocariasis

Case #2: JG

• 47 year old man, lawyer

• PMH: depression, hyperlipidemia, GERD

• Worsening left back pain for 1 week after skipping on concrete

• Taking naproxen, flexeril, Tylenol#3 with no relief

Case #2: JG

• HR 83, BP 134/83, Temp 36.7, RR 18

• Normal examination, no red flags

• CT L spine done showing L5‐S1 disc protrusion and L5 nerve compress

• Given Valium 5, Toradol 30, Tylenol 1000, improved

• Script for Percocet

Case #2: JG

• Anything different?

• Thoughts about diagnosis?

Case #2: JG

• Went to Sunnybrook 4 days later with significantly increased back pain and discharged home

• Next day, family doctor ordered private MRI

• 2 days later sent by Dr. to ER with ongoing back pain and bilateral leg numbness

• Thoughts?

Case #2: JG

• 13 days low back pain radicular both legs, night sweats

• HR 94, RR 18, BP 118/73, Temp 36.4

• Looks pale and unwell, tender midline L4‐5

• Brisk reflexes and 2+clonus bilateral

• WBC 11.4, Hgb 116, plt 208, lytes, liver kidney normal

• ?

Case #2: JG

• MRI from CML:• L1‐S1 epidural soft tissue mass extending into muscles and fascia

• ?abdominal mass – likely lymphoma or metastatic disease or infectious

Case #2: JG

• Referred to neurosurgery

• IV Ceftriaxone/Vancomycin

• Full spine MRI, CT chest and abdomen ordered

• ESR 69

Case #2: JG

• Patient deteriorated – agitation then unresponsive Intubated

• CT shows mediastinal abscess

• MRI shows large epidural abscess with extension into muscles and significant cauda equina compression

• ECHO normal, no endocarditis

Case #2: JG

• OR: • Thoracics explored mediastinum

• Neurosurgery drained and debrided spinal abscess

• Blood C&S 3/3 MSSA, urine C&S MSSA, tissue C&S 4/4 MSSA

• IV Cloxacillin for 6 weeks

Spinal Epidural Abscess

• Incidence 1‐2 per 10,000 admissions

• Epidural space between dura and vertebral column

• Most prevalent in:• >50 years old

• male

• T4‐8 (50% thoracic) and L3‐S2 (35% lumbar) due to larger posterior space


• Delayed diagnosis worsens morbidity and mortality• need surgery within 24 hours (worse deficit at surgery = worse outcome)

• 10% mortality


• Staph aureus 60%, Strep 9%, Gram ‐ve Rods (10%), Anaerobes (2%)

• Source: • 30‐40% of cases have no identified source

• skin (18%)

• UTI (10%)

• pneumonia (5%)

• endocarditis (3%)

• prosthesis – vascular access (2%)

• osteomyelitis, retropharyngeal abscess, pressure sore, psoas abscess, trauma, back or epidural injection, spinal stimulator


• Risk Factors:• Immunocompromise (55%)

• DM (21%), medication (12%), cancer (7%), HIV (6%), alcoholic (5%), CKD(4%)• Alcohol – injury, decreased pain sensitivity, symptoms misinterpreted

• IVDU (15%)

• Trauma (15%)

• Recent procedure or Adjacent infection


• Complications:• death from sepsis/meningitis or panspinal abscess

• cord dysfunction (paralysis from direct compression, spinal ischemia, local thrombosis)


• Classic triad of back pain, fever and neurologic deficit only 10‐15%

• May not have fever nor neuro deficit when most important to diagnose

• Progression takes days to weeks, unpredictable – often missed!


• Signs & Symptoms: • localized back pain (75%)

• tenderness (58%)

• fever (32%)

• weakness (40%)

• radicular pain (38%)

• paresthesia (36%)

• bowel/bladder dysfunction (27%)

• stiff neck (16%)


• Lab test:• WBC elevated 70%

• ESR >20 in 95%,

• high CRP

• CT may be diagnostic

• Gadolinium MRI is gold standard (sp and sn 90%)


• IV Cefotaxime + Vancomycin for 4‐6 weeks• May tailor antibiotic after C&S

• Neurosurgical referral for drainage and decompressive laminectomy, OR aspiration

Spinal Epidural Abscess – take home points

• Mechanical back pain is most common and benign

• Consider imaging if worsening symptoms

• With unwell looking patient or hard neurologic findings involve Neurosurgery/Radiology EARLY

Case #3: JL

• 71 year old man

• PMH: sigmoid CA with liver mets (2004), right hepatectomy (2010)

• 3 days ago discharge from Ajax after a 1 week stay for pyelonephritis• E.Coli in urine and blood. Had normal CT in Ajax

• On Cipro for 7 days

• Tmax 105F at home, general malaise

• Intermittent bilateral flank pain radiates to groin

Case #3: JL

• Thoughts?

Case #3: JL

• HR 94, RR 19, BP 103/68, Temp 37

• Exam normal (resp, cardiac, neuro, abd)

• Lytes normal, Cr 106, AG 15, WBC 10, hgb 134, plt 276

• Bili 31, AST 97, ALT 93, ALP 446, urine normal

• CT ABD: normal

• Discharged with Rapid Internal Medicine follow up

Case #3: JL

• Anything different?

Case #3: JL

• ER called by radiologist 2 hours after discharge:

• L5‐S1 increased soft tissue mass 3x1.4 cm

Case #3: JL

• Patient returned, referred to GIM

• In ER for 24 hours, no fever, normal vitals

• ESR 73, CRP 150

• MRI: L4‐S1 epidural abscess, compressing S1 nerve and thecal sac, discitis L5‐S1

• Admitted for increased Cipro dosing, then discharged

Case #3: JL

• 6 weeks later returns to ER post antibiotics

• Worsening back pain, severe now, temp 37.8

• Midline spinal tender, normal neuro exam

• Thoughts?

Case #3: JL

• MRI:• progression discitis and osteomyelitis L5‐S1, abscess and phlegmon

• CT guided drainage

• IV Vanco/Ceftriaxone for 6 weeks.

Spinal Epidural Abscess – take home points

• Does not present typically and ALWAYS maintain index of suspicion

Case #4: CC

• 65 year old woman

• PMH: CHF, Polycythemia Rubra Vera, Hysterectomy

• 2 days of diffuse crampy abdominal pain, bloating, nausea

• Unable to eat due to pain

• Today at work vomit x 1 and syncope

Case #4: CC

• HR 96, BP 90/50, RR 20, Temp 36.7

• Diffuse tender with guarding and rebound worse in RLQ and LLQ

• POCUS no free fluid, normal aorta <2 cm

Case #4: CC

• CXR normal

• WBC 40, plt 1476, Hgb 138, Cr 124, lactate 2.5

• Urgent CT

• Thoughts?

Case #4: CC

• Syncope in CT 1335, then c/o shoulder and back pain with sweats

• BP over next hour:• 100/60• 80/50• 90/70• 70/50• 70/40• 50/20

• ??

Case #4: CC

• 15:10 Hgb 75, lactate 5.9

• CT ABD: • Large hematoma and hemoperitoneum 10x6x20 cm.

• Extravasation appears from SMA branch.

• ?What next?

Case #4: CC

• 15:15 to IR – blood and fluids pushed

• STAT Angiogram and Embolization

• Bleed from right colic and ileocolic branch of SMA

• Coil to bleeding branch of SMA at right colic artery

• Continue bleed from right superior ileocolic artery • attempted to cannulate but caused dissection and reduced bleeding

SMA rupture

• Visceral branch aneurysms 0.1‐2% of abdominal aortic aneurysms• SMA is 3rd most common of these

• Caused by:• arteriosclerosis, fibromuscular dysplasia, c.t. disease, infection (mycotic), dissection, pancreatitis, trauma, lupus, TB

• Hard to detect until rupture – pain and shock

• Treatment is embolization or surgery

Case #4: CC

• Patient got worse after IR • Increasing Abdominal Pain

• Anion Gap Metabolic Acidosis, decreased bicarbonate

• Lactate 5.6

• Increased oxygen demand

• Thoughts?

Case #4: CC

• Gen Sx called:• Abdomen very tense

• Bladder pressure 26

• To OR for laparotomy from ICU• Removal of 5 L blood

Abdominal Compartment Syndrome

• Usually from SIRS which causes capillary leak into interstitial space

• Large volume of tissue fluid > wall compliance threshold Can no longer stretch, so further fluid causes rise in pressure in closed space

• High intra‐abdominal pressure (>12) reduces blood flow to organs Impairs organ function (>20) leading to MODS and death

Abdominal Compartment Syndrome

• Results in:• compression, infection, renal failure, increased airway pressures,

increased ICP, decreased cardiac output

• Secondary to:• trauma, peritonitis, fluid resuscitation, hematoma, reperfusion, pancreatitis, obstruction, mass, packing, ascites

• high mortality unless operative decompression

SMA rupture – take home points

• LUQ abd. pain is usually benign

• Urgent non‐contrast CT if patient looks unwell or worried• IR vs. OR decision

• Beware syncope and abdominal pain watch vital signs

Case #5: DB

• 29 yo woman

• PMH: B12 deficient, LEEP

• Ran obstacle course and right after developed 10/10 pain

• LUQ abdominal, sudden onset, ongoing for 20 minutes

• Described as sharp, colicky/crampy, pleuritic component

• Thoughts?

Case #5: DB

• HR 113, RR 18, BP 121/71, Temp 36.5

• Tender LUQ, equivocal rebound, guarding

• WBC 11.9, Cr 79, lactate 1.7, Bhcg –ve, lipase 35

• POCUS 16.3 spleen, multiple cysts (largest 7x7x3), free fluid LUQ

Case #5: DB

• CT: large free fluid, posterior rupture splenic cyst

• ID: Low suspicion of echinococcus – no travel, no histaminic reaction

• GenSx: OR for splenectomy, serosanguinous fluid from cyst

Splenic Cyst

• Incidence is 0.05%

• Usually asymptomatic or minor GI symptoms from mass effect

• Rupture, bleed and infection may be life threatening

• Causes: • 60% parasitic (hydatid)

• 30% post trauma pseudocyst

• 10% congenital, vascular, lymphatic, neoplastic

Splenic cyst

• Management: No consensus • aspirate? inject with alcohol? cyst excision? splenectomy?

• Hydatid cyst:• Echinococcus is a tapeworm, not endemic to North America

• Rupture causes IgE mediated reaction

• Prior to surgery antiparasitics prevent dissemination of echinococcus

Splenic cyst rupture – take home points

• LUQ pain is usually benign

• POCUS can be helpful in unwell patients

• Pay attention to pain out of proportion

Case #6: JS

• 34 year old man

• PMH: schizophrenia, polysubstance abuse, withdrawal seizure

• Meds: risperidone, phenytoin

• Brought by ambulance, found intoxicated sleeping on sidewalk

• No voiced complaints

Case #6: JS

• HR 96, BP 150/92, RR 12, O2 sat 96%, Temp 36.6, smells of EtOH

• GCS: Eyes=4, Verbal=2(sounds), Motor=1

• H+N: no trauma

• Chest, CVS, Abd normal

• Ext: not moving arms nor legs, but not flaccid

• ?Thoughts

Case #6: JS

• After 1 hour no clinical change

• Labs: EtOH 0, ALT 55, AST 75, glucose 6• CBC normal, lytes normal, Cr normal

• Now what?

• Re‐examine: some saccadic movements of eyes….

Case #6: JS

• Patient given 2 mg lorazepam• 15 minutes later awoke and was speaking

• Phenytoin level was zero• Phenytoin loaded and discharged with prescription

• Skipped off happily and…

• He will be coming to an ER near you!

Non‐Convulsive Status Epilepticus (NCSE)

• “persistent change in behaviour and/or mental processes from baseline without major motor signs”

• No universal definition, wide range of syndromes

• Usually respond to anticonvulsants

• Subtle motor signs may be present • twitching, blinking, fluttering, automatisms, jerks, eye deviation, speech disorganization, aphasia


• Occur in 8‐37% of general ICU population (comatose)

• Can be absence, generalized, complex partial

• Diagnostic challenge• High index of suspicion in patients with risk factors and clinical features

• Difficulty differentiating from non ictal causes • drugs, metabolic, hypoxic, septic, encephalopathy

• Delayed diagnosis, EEG may not be diagnostic


• Suspect it in patients with:• Prolonged post‐ictal period

• Altered sensorium with subtle signs (twitch, blink) or fluctuating mentation

• No other cause of altered sensorium, and prior seizure history

• Unexplained confusion and antipsychotic medication

• Stroke patients who look worse than expected


• Risk factors:• Sepsis and pre‐existing seizure disorder

• Stroke, SAH

• Encephalitis, dementia

• Neurosurgery, brain tumour

• Withdrawal of benzo/alcohol

• Intoxication (drugs/alcohol)

• Trauma


• Symptoms:• Coma, catatonia, psychosis, speech disorder, subtle motor signs

• Differential:• Encephalopathy, migraine, amnesia, hypoglycemia, post ictal, pseudocoma, intoxication, withdrawal, TIA

• Management:• Early recognition and anticonvulsants

• Benzos, phenytoin, valproate,

• Supportive care, treat underlying cause

NCSE – take home points

• Most altered patients are not having a seizure

• Maintain index of suspicion based on risk factors in the right patient

• If uncertain in a risky patient, trial of benzodiazepines

Case #7: DR

• 59 yo woman

• 1‐2 years of slurred speech, off balance, poor memory, blurred vision, urine incontinence, dizziness and intermittent muscle spasm

• Feels worse this morning

• Ataxic gait, remainder of exam normal

• Thoughts?

Case #7: DR

• CT: • extensive calcification of cerebellar, pons, basal ganglia, cerebral cortex white matter

• ?Fahr’s disease or endocrine calcium metabolism disorder

Fahr disease (Familial Idiopathic Basal Ganglia Calcification)• Genetic disorder with calcium deposits in brain starting with BG

• Progressive disorder

• Usually presents 30‐50 years old

Fahr disease (Familial Idiopathic Basal Ganglia Calcification)• Parkinsonian symptoms

• Poor motor function, dysarthria, muscle spasm, dementia, vision impairment

• Unsteady gait, dysphagia, seizure, depression, poor memory, incontinence

• Differential includes parathyroid and calcium disorders, CSF infection

• Management of symptoms: Levodopa, psychiatric medication

Fahr’s disease – take home points

• Consider imaging in ataxic patients

• Neurology consults can be helpful

Conclusion

• Watch for atypical symptoms and symptoms out of proportion

• Consider imaging in worsening condition or sick patients

• Painful floaters and abdominal pain with syncope are red flags

• Remember: common things are still common

“When you hear hoofbeats, think of horses, not zebras”

Theodore Woodward

Documents

Theodore Woodward, Nobel prize Dr. Peter Switakowski, MD · 2017-09-14 · Case #2: JG • Went to Sunnybrook 4 days later with significantly increased back pain and discharged home