3/20/18 Resident Morning Report – Right Foot and Hand Pain, Swelling, and Erythema; Vaginal Discharge; Septic Joint; Disseminated Gonococcal Infection

CC: Right foot and hand pain

HPI: This is a 40 year-old female with a history of intravenous drug use (last use 1 year prior to admission), who presented with a chief complaint of right foot and hand pain with accompanying swelling and erythema of both aforementioned extremities. The pain had begun approximately 1 month prior to admission and initially was localized to her right ankle, eventually migrating to include her right hand, again with accompanying swelling and erythema. She noticed no drainage from areas of involvement but did endorse subjective fevers and chills as well as incidentally noted suprapubic tenderness and vaginal discharge. Her past medical history was notable for gallstone pancreatitis for which she had had a cholecystectomy. She was sexually active with one partner and used barrier protection occasionally. Her vital signs on admission were within normal limits. Her right hand was noted to have erythema of the volar palm that extended to the 3rd digit and included a 2 cm x 3 cm area of fluctuance of the mid palm; she reported pain with active range of motion and passive extension. Her third digit was held in the flexed position. Her right ankle and dorsum of the right foot also demonstrated significant erythema and swelling, again with a 2.5 cm x 2.5 cm area of fluctuance to the dorsolateral midfoot with painful passive and active range of motion throughout the ankle and foot. Genitourinary exam was notable for moderate, thin, yellow discharge of the introitus but without cervical motion tenderness or cervix friability.

Labs/Diagnostics:

Cervical Swab:

Chlamydia RNA: negative
Gonorrhea RNA: positive
Wet mount: Trichomonas observed; no yeast cells or clue cells observed

Right Ankle Aspirate:

Nucleated cell count: 2700
Segmented neutrophils: 70%
Lymphocyte: 26%
Monocyte/histiocyte: 4%
No crystals observed

Right Foot and Right Hand Wound Cultures

1+ Neisseria gonorrhea
Anaerobic culture negative

Patient undergoes joint aspirate and wound cultures from her pustular lesions. A diagnosis of disseminated gonococcal infection is made and supported by positive findings on her cervical swab. Patient was continued on antimicrobial therapy with a plan to treat for a full course of 7 days.

Morning Report Pearls:

Disseminated gonococcal infection is the most common cause of polyarthralgias in young, otherwise healthy patients who are sexually active
There are two classical forms of presentation in disseminated gonococcal patients:
- Arthritis-dermatitis syndrome is a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis
- Purulent arthritis is similar to a septic joint in presentation and laboratory findings
Joints involved can include both large and small joints with the migratory nature of the disease distinguishing it from other causes of septic arthritis
- Symmetric joint involvement is uncommon
Skin findings are common, especially in arthritis-dermatitis syndrome and typically present as painless, pustular, or vesiculopustular, rarely resembling erythema nodosum or erythema multiforme
Isolation of the organisms can establish the diagnosis of disseminated infection; patients with risk factors or with suspected disseminated infection should be swabbed for evidence of urogenital, rectal, or pharyngeal involvement via nucleic acid amplification testing
- Though positive in this case, testing of skin lesions is not typically part of the typical evaluation given their low yield
- Synovial fluid may also only be positive in approximately 50% of cases but with positive mucosal site testing and suspicious clinical presentation, a presumptive diagnosis can be made
Treatment of susceptible organisms with third-generation cephalosporins for a total of 7 days (or 14 days if evidence of septic arthritis)

2/13/18 Resident Morning Report – Bright red blood per rectum, abdominal pain, IBD.

CC: Bright red blood per rectum, abdominal pain

Case Presentation: 27yr old male Guatemalan immigrant with no past medical history presents with complaints of bloody stools for seven months. The patient notes 9-10 bowel movements per day. He describes bowel movements as loose and explains that roughly half of his bowel movements are bloody. The patient describes stools as blood streaked with bright red blood on toilet paper. His bowel movements are associated with daily cramping non-radiating diffuse abdominal pain that is somewhat relieved after having a bowel movement. Over the course of seven months leading up to his presentation, the patient has noted approximately 35lb unintentional weight loss. He notes progressively worsening excessive fatigue and dizziness but denies fevers, chills, sweats, pre-syncope/syncope, nausea, vomiting, chest pain, SOB, palpitations, dysuria. He denies any visual changes, joint pain, rashes, oral ulcers. He has no significant past medical histories or allergy and is not taking any medication. His family histories are also unremarkable for autoimmune disease or GI/GU cancers. He is a social smoker but no other illicit substances or alcohol use. On exam, he was tachycardic to 137bpm on presentation, hypotensive to 86/46, afebrile, and breathing on room air saturating at 100% SaO2. There is no abdominal distention, soft, and mild tender throughout all four quadrants. The digital rectal exam did not reveal any gross blood, melena, visible ulcerations, or palpable masses. Extremities are warm to touch with strong capillaries refill and symmetric 2+ DP/PT pulses. Neurologic exam is nonfocal. The complete metabolic panel was unremarkable. Complete blood count was significant for a normocytic anemia with elevated RDW, a neutrophilic predominant leukocytosis without a left shift, and thrombocythemia.

Other pertinent workup:

Iron panel: serum iron 20 mcg/dL; TIBC 152 mcg/dL; iron sat 13%; ferritin 145 ng/mL

ESR 52 mmh/hr

CRP 155.1 mg/L

Lipase 13

C. Diff stool toxin negative

Blood culture x 2 negative

Stool culture negative

Stool O&P many white blood cells. No ova or parasites.

Giardia stool Ag negative

Quantiferon gold negative

Hepatitis A IgG positive (Otherwise Hepatitis serologies negative)

CT Abdomen/Pelvic with contrast: Diffuse contiguous bowel wall thickening from rectum to transverse colon. Proxmial jejunum thickening. Malrotation of SMV to the left of SMA. Small paraesophageal hernia. Diffuse osteopenia.

Hospital Course: Patient was admitted for sepsis due to (WBC >12k, tachycardia, hypotension, likely GI source), blood cultures, stool studies, ESR/CRP sent, CT abdomen pelvis showed contiguous diffuse bowel wall thickening, patient was started on empiric antibiotics (ceftriaxone and flagyl). GI was consulted and recommended starting solumedrol 20mg overnight. Next day, colonoscopy was performed which showed findings consistent with ulcerative colitis (Mayo UC endoscopy score II/III). The patient was continued on IV solumedrol with a plan to transition to biologics. Supplemental testing (hepatitis, HIV, Quantiferon gold) performed in preparation for biologics. Patient clinically improved over the next 3 days with downtrending CRP to 10.8 (from 155) and was transitioned to oral prednisone on the day of discharge. Plan to obtain outpatient MRE small bowel follow through to evaluate for strictures and GI follow up.

Morning Report Pearls:

IBD encompasses both UC and Crohn’s disease, both of which are clinically distinct and overlapping disorders of the GI tract.

Ulcerative Colitis (UC): submucosal, limited to colon, 95% involves the rectum and often extends proximally in contiguous nature.
Crohn’s disease (CD): transmural, anywhere from mouth to anus, often in a skip lesion pattern. Propensity for fibrosis, obstruction, stricture, and perforation.

IBD has a Bimodal distribution that most commonly occur in patients ages 15-40 and 50-80. Affects men and women equally, as well as all races and ethnicities; though more commonly seen in Ashkenazi Jews.

When approaching suspected presentation of IBD, important differential diagnosis to consider are infectious mimics of IBD including C. difficile, Shigella, Salmonella, Camylobater, Yersinia, Amoebiasis, and EHEC. CMV, HSV, KS are important to consider in immunocompromised host. Other considerations includes appendicitis, diverticulitis, ischemic colitis, celiac sprue, radiation enteritis, GI cancer, lymphoma.

Initial workup should focus on ruling out infectious causes (Stool O&P, culture, C. diff, CRP, serology for celiac sprue if indicated). C. diff toxin and CT abdomen should be considered first in acute presentation or if the patient is unstable for colonoscopy.

Treatment is targeted based disease severity and should typically be managed by GI/IBD specialist.

Mild (<4 BMs/day, with or without blood)
Moderate (>4 BMs/day, with or without blood)
Severe (>6 BMs, usually with blood and s/sx of systemic toxicity e.g. fever, tachycardia, ESR/CRP elevation, anemia)
Fulminant (>10 BMs, continuous bleed, abdominal distention and tenderness, toxic appearing )

Important to obtain the following prior to initiating immunomodulator therapy:

PPD/Quantiferon Gold
Hepatitis serologies (particular hepatitis B due to risk of reactivation)
TPMT level

From a primary care standpoint, annual or biannual surveillance colonoscopies with biopsies are indicated for cancer surveillance 8-10 years after initial diagnosis of UC due to markedly increased risk of colorectal cancer.

Lastly, an important fun fact to know is that smoking is protective for UC but worsens for Crohn’s disease.

2/2/18 Intern Morning Report – Shortness of Breath, Generalized Weakness, Dysphagia, New Onset Atrial Fibrillation, Hypoxia, Normal A-a Gradient, Myasthenia Gravis

CC: Shortness of Breath

HPI: 80 year old Chinese female with no past medical history presented to the emergency department with shortness of breath and dyspnea on exertion over the past week. She noted orthopnea with an inability to sleep and continued worsening exercise intolerance. She denies fevers, chills, nausea, vomiting, or diarrhea. At baseline, she is usually independent and active without limitations. On review of systems, she additionally reports dysphagia and generalized weakness. On exam, her heart rate is 142 and irregularly irregular. She is hypoxic to 82% on room air and has poor inspiratory effort but lungs are clear. There is evidence of left eye ptosis on exam which she says has been chronic in nature. Basic labs are normal, EKG demonstrates atrial fibrillation, and CXR shows small lung volumes with bronchovascular crowding. No initial ABG drawn.

Hospital Course: Patient admitted for rate control of her atrial fibrillation and diuresis for which patient received metroprolol and lasix IV as well as initiation of a heparin drip. A couple days into her hospitalization, patient became lethargic and was found to have the following ABG: 7.10/107/97/33 while on 5L NC, requiring intubation. Post-extubation, she had recurrent episodes of hypoxia necessitating intermittent BiPAP. Though patient only had unilateral ptosis, with this reported symptom as well as report of dysphagia, and hypercapnic respiratory failure with no obvious etiology, suspicion for MG was high. See the work up below that confirmed the diagnosis.

Work up for Myasthenia Gravis:

Acetylcholine Receptor Binding Ab – 124.5 (H)

Acetylcholine Receptor Modulating Ab – 88% binding inhibition (H)

Acetylcholine Receptor Blocking Ab – 51% of inhibition (H)

Striated Muscle Ab – Positive

EMG: positive for post-synaptic neuromuscular junction disease.

Morning Report Pearls:

Hypercapnic Respiratory Failure has only a hand full of etiologies that can be broken down into whether there is a A-a gradient or not:

Extra thoracic Causes (Normal A-a gradient)
1. Decrease respiratory drive (medication induced or CNS lesion like mass or stroke)
2. Neuromuscular Disease (Myasthenia, GBS, ALS, spinal cord disease, myopathy)
3. Chest wall compliance issues (kyphoscoliosis, obesity)
Intrathoracic Causes (High A-a gradient)
1. Pulmonary fibrosis (late stage usually)
2. Athma
3. COPD
4. Bronchiectasis

Using your ABG to differentiate the two in addition to a great history and exam can be helpful!

Very important in MG patients is avoiding medications that exacerbate their condition. This patient likely decompensated due to the cardiac medications given to her to control her atrial fibrillation.

Medications that unmask or worsen MG are extensive but here are a few:
-Anesthetics

-Antibiotics like aminoglycosides, clindamycin, fluoroquinolones, vancomycin

-Cardiovascular drugs like beta blockers, quinidine

-Magnesium

Lastly, one unique feature of this case is the cardiac manifestation of her MG, atrial fibrillation. A variety of arrhythmias have been documented in MG cases including sinus bradycardia, atrial premature beats, and atrial fibrillation. Other cardiac manifestations include Takostubo’s cardiomyopathy and giant cell myocarditis.