8/9/17 Resident Morning Report – Dyspnea on Exertion, Fatigue, Conjunctival Pallor, Splenomegaly, B12 deficiency, Pernicious Anemia

CC: Dyspnea on exertion

ID: 42 yo male with no past medical history presents with dyspnea on exertion and fatigue for 3 weeks. He becomes short of breath with walking ½ block when his baseline was walking miles. He has no chest pain, paroxysmal nocturnal dyspnea, lower extremity edema, cough, or orthopnea. In addition he reports unintentional weight loss of 10 lbs over 3 months, low appetite, and night sweats. Social history is pertinent for drinking six 24 oz beers per day. His exam is notable for conjunctival pallor and hepatosplenomegaly. See the following notable labs:

LDH >5000

Haptoglobin <20

Retic 2.5%

Overall picture is consistent with ineffective erythropoiesis. The peripheral smear demonstrates macrocytic red blood cells and hypersegmented PMNs, narrowing the diagnosis to folate and/or B12 deficiency. His B12 returned as <100 and Homocysteine/MMA elevated confirming that patient had significant B12 deficiency leading to his pancytopenia. IF-Ab and Parietal Cell Ab were positive which made Pernicious Anemia the most likely cause given lack of other malabsorptive conditions, though patient likely had poor nutrition from his alcohol use complicating the picture.

Morning Report Pearls:

Pancytopenia is a broad differential including infection (EBV, CMV, HIV, Cocci, Histo, TB), rheumatologic conditions (RA, SLE, Sarcoid), drugs, nutritional deficiencies (B12, folate and copper), Zinc toxicity, Lymphomas/Leukemias, Myeloproliferative disorders like MDS and Myelofibrosis, Aplastic Anemia, Liver disease, Alcohol toxicity, Amyloidosis, HLH, Metastatic cancer – see prior Morning Report Post from 5/19/17

Macrocytosis is classically seen in a few of these causes: B12/folate deficiency, MDS, Alcohol toxicity, and Liver disease

Peripheral smear is your friend and can cinch the diagnosis when you see hypersegmented PMNs like in this case of B12 deficiency

Once the diagnosis of B12 deficiency is made, you need to think of causes: malabsorption (due to IBD, celiacs, tropical sprue, gastric bypass), medications (PPI, metformin), pernicious anemia, malnutrition

If patient not responding to B12 supplementation, consider pursuing a diagnosis of MDS with bone marrow biopsy. Indirect bilirubinemia and the elevated LDH should improve within 1-2 weeks following B12 treatment but cell counts can take months to normalize.

8/2/17 Resident Morning Report – Shortness of breath, Saddle nose deformity, Tracheobronchial narrowing, Relapsing Polychondritis

CC: Shortness of breath

ID: 51 yo female with history of hypothyroidism, seronegative rheumatoid arthritis, and systemic lupus erythematosus who presents with complaint of worsening shortness of breath over 2 weeks. Her shortness of breath is not positional or related to exertion but she has associated dry cough and hoarse voice. There are no systemic symptoms mentioned like fevers, chills, or weight loss. Review of systems is notable for ear swelling that occurred 3 months prior. On exam she has saddle nose deformity and inspiratory stridor but otherwise lung exam is clear. Labs are at baseline for the patient and chest x-ray shows no infiltrates or mediastinal widening. CT scan of neck and chest demonstrate narrowing of the trachea and bronchi, and upon direct visualization via laryngoscopy and bronchoscopy patient is without any noticeable granulomatous changes. Given history of ear involvement, saddle nose deformity, and tracheobronchi narrowing, patient diagnosed with Relapsing Polychondritis.

Image used with permission from Visualdx

Morning Report Pearls:

Exam findings of saddle nose deformity and inspiratory stridor should alter the differential to include Granulomatous Polyangitis (GPA) and Relapsing Polychondritis (RPC) given their propensity for upper airway and sinus disease
Just for fun, here are some other causes of saddle nose deformity: Trauma, Cocaine use, Leprosy, Congenital Syphilis
What type of flow loop would be seen in this patient?
- Fixed upper airway obstruction

Diagnosis of RPC is clinical fulfillment of McAdam’s Criteria (need 3 of 6):

Recurrent chondritis of auricles
Non-erosive inflammatory polyarthritis
Chondritis of nasal cartilages
Chondritis of respiratory tract
Cochlear and/or vestibular damage
Conjunctivitis/Keratotis/Scleritis/Uveitis

7/18/17 Resident Morning Report – Abdominal pain, Bloody diarrhea, Weight loss, Crohn’s, Pyoderma Gangrenosum

CC: Abdominal pain, bloody diarrhea

ID: 29 yo F with history of eczema presenting with abdominal pain and diarrhea for 1 month. The abdominal pain is described as intermittent, cramping, and diffuse. Her bowel movements changed to watery then bloody, with 3-8 episodes per day. She has associated nausea, vomiting, poor appetite, and 10lb weight loss for the same period of time. Exam findings are pertinent for a new rash on her right thigh that is ulcerative with purulent base (see picture below). Colonoscopy demonstrated a normal rectum but colon had noticeable changes of ulcerations, pseudopolyps, edematous and friable mucosa. Biopsy of affected area confirmed diagnosis of Crohn’s disease and biopsy of skin lesion was consistent with Pyoderma gangrenosum.

Image used with permission from VisualDx

Morning Report Pearls:

1. Always be on the look out for extra-intestinal manifestations when IBD is on the differential. They can appear at various times during the disease course. Here are some:

Episcleritis, Scleritis, Uveitis
Peripheral arthritis – Type I and Type II
Erythema nodusum
Pyoderma grangenosum

BOLD = correlates with disease activity

2. Skin findings seen in IBD can be seen in a multitude of other conditions.

Pyoderma grangrenosum can be seen in hematologic malignancies and rheumatologic conditions like RA and AS
Erythema nodusum can be seen in many different infections – Streptococal infection, TB, Mycoplasma, Cocci, Blasto, Histo as well as in Sarcoid, Behcets, Lymphoma