5/4/18 Intern Morning Report – Shortness of Breath, Cough, Unintentional Weight Loss, Bloody Pleural Effusion, Asbestosis, Malginancy

CC: Shortness of breath and cough for 2 weeks

HPI: This is a 65-year old female with no past medical history presenting with two weeks of shortness of breath and cough as well as three weeks of generalized malaise.  She received a five day course of azithromycin prescribed by her primary care physician with no improvement in symptoms.  She is from Northeastern China and moved to Los Angeles in the 1990s.  She works at and owns a pencil manufacturing factory for ten years . She denies any smoking or alcohol use. Review of systems is pertinent for unintentional weight loss of 10 lbs over the last month.  Physical exam shows the patient to be afebrile, heart rate in the 130s, tachypneic to 22, and sat’ing 96% on room air.  Her rhythm is regular and pulmonary exam demonstrates evidence of a pleural effusion (decreased breath sounds in left lung base, dullness to percussion in the left lung field with decreased tactile fremitus).



CT Chest: Bilateral calcified pleural plaques are present with left pleural thickening.


Pleural fluid is grossly bloody with the following studies:

  • Glucose 72
  • LDH 1100
  • Protein 5.3
  • Color: Red
  • Markedly bloody
  • 902 nucleated cells
  • 84% segmented neutrophils
  • 16% lymphocytes
  • Pathology did not show malignant cells

Body Fluid Comparison

  • Glucose 90
  • LDH 161
  • Protein 6.6

Initial cytology is negative, so the favored diagnosis at the time is BAPE.  However repeat cytology done, showing atypical cells most consistent with Invasive Ductal Carcinoma primary site likely breast.  Patient is eventually diagnosed with breast cancer that is ER+/PR+/HER2 negative.

Morning Report Pearls:

Grossly bloody pleural effusions can narrow your differential to: Malignancy, Trauma, Asbestos, Pulmonary infarct, and Infection


Hemothorax is when the Hct in the pleural fluid is >50% of serum.  Important to know because chest tube placement would be indicated.


Benign Asbestos Pleural Effusion came up on this differential given the fluid being bloody, exudative and with a CT showing calcified pleural plaques.  Just remember that BAPE is a diagnosis of exclusion!  Malignancy should be ruled out first particularly given the elevated risk with asbestos exposure.


Risk Factors to know with regards to asbestos exposure include construction, automotive servicing, mining workers and shipbuilding industries.  When exposed the shorter fibers are typically cleared from the lungs however the longer fibers are transported to the interstitium or to the lymphatics where they can reach the pleura.  Most common finding in asbestos related pleural diseases is parietal plaques followed by pleural fibrosis and pleural effusion.  Pleural fibrosis can cause a restrictive disease if diffuse.  BAPE is almost always hemorrhagic as mentioned above and eosinophils can be elevated in 1/3.  Mesothelioma is a potential cancer that can be difficult to exclude in cases suspicious for BAPE given the low sensitivity of cytology so pleuroscopy may be needed.


Lung cancer is the most common malignancy to cause a pleural effusion and asbestos exposure does increase the risk of lung cancer.  Other cancers that can commonly lead to pleural effusion to consider are breast cancer and lymphoma.

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.