Nagging cough in a young male

Clinical scenario :

              A 31-year male an accountant by profession, presented with a persistent cough of six weeks duration. The cough was dry and he denied any history of allergy in the past or any chronic medication. The patient is a non-smoker and also denied any loss of appetite or loss of weight or close contact with any sick patient. There was no history of fever, sweating. He had no change in his voice. There was no history of palpitations, PND or orthopnea. No history of Tuberculosis in the past.  

Examination: 

            He had stable vitals and normal oxygen saturation on room air.

Chest examination: Trachea in the center , The percussion note was normal and on auscultation, there were no added sounds, normal bronchovesicular breath sounds were heard all over.

CVS: S1 and S2 were normally heard There was no murmur, rub or gallop 

Abdomen: Normal 

CNS: Normal 

Evaluation and Hospital course: 

           The  Hemoglobin levels were 14gm/dl and WBC count and platelets were normal. ESR was 4 mm in the first hour. The tests on Kidney and liver function were normal.    

Chest X-ray PA view was  unremarkable 

Keeping in view his nagging cough  CT scan chest was done as shown in Fig 1 : A cystic lesion at the azygocaval junction was noted. No other lesions were seen 

Fig1 Cystic hygroma at right azygocaval junction 

         The patient was subjected to Video-assisted thoracoscopic surgery  (VATS) and the lesion was resected. It turned out to be Cystic hygroma. The patient had a marked relief and is following our clinic

Teaching message : 
        
        A normal X-ray chest doesn't rule out all pathological processes in the symptomatic patient. 

Further reading click the link:  Cystic Hygroma

Glue injection in fundal varices

Glue injection in Fundal varices 

Abdominal mass in a young male

Clinical scenario:  
         A 35-year-old male farmer had noticed a swelling of the left side of his hypochondrium that persisted for six months. He had no history of severe abdominal pain, jaundice or fever. There was no history of loss of appetite or weight loss.
Examination:
       The patient was conscious and oriented. Icterus, lymphadenopathy, and edema were absent. The examination of his abdomen revealed a swelling that measured 5x6 cm. The swelling was smooth and cystic. In order to confirm the origin of this swelling different maneuvers were used. The swelling disappeared while raising his head suggesting an intraabdominal nature of the swelling. The patient was asked to assume the knee-elbow position and the swelling was palpated in this position. The said swelling disappeared confirming the retroperitoneal nature of this swelling. There was no bruit on auscultation. The results of the systemic examination were normal.


Evaluation: 
         He had normal levels of hemoglobin(Hb= 13.6gm/dl), white cell count and erythrocyte sedimentation rate were normal as well.
Tests of kidney and liver function were normal and serum amylase levels were not increased. His
chest X-ray was normal. On ultrasound examination, there was a 7x6 cm swelling surrounding the
pancreas was documented. The liver, gallbladder and other organs were normal. His abdominal computed tomography

Fig 1 CT scan abdomen showing Cyst in tail region of Pancreas 

(CT) revealed a cyst in the tail of the pancreas but the pancreatic duct was not dilated. The cyst was 5x6 cm in diameter, and had jagged margins but did not contain daughter cysts. All other organs were normal (Figure 1). No additional cystic lesions were seen in any other organ. IgG antibodies to E. granulosus were detected by enzyme-linked immunosorbent assay (ELISA).
Course: 
       The patient was given albendazole 15 mg/kg perioperatively, and distal pancreatectomy and enucleation of the cyst with proper precautions were done to prevent anaphylaxis.
Splenectomy was also performed and hemostasis was achieved. A drain was left in place after the procedure. Histopathology was suggestive of a hydatid cyst.
The patient had high blood sugars postoperatively and was managed with insulin subcutaneously. He had an uneventful course. He was discharged from the hospital after eight days. The patient's blood sugars are under control with insulin. The patient was monitored for six months in our outpatient department.

Teaching message : 
            The hydatid cyst  may be considered as one of the differential diagnosis  in the cystic lesions of the pancreas 

Further Reading:      Hydatidosis

An unusal cause of recurrent abdominal pain

   Clinical scenario :
A 27-year-old   male with no significant comorbidities presented with a history of episodic, recurrent abdominal pain of 4 years duration. The patient described the pain as colicky, remaining for 1–2 hours necessitating intravenous analgesics predominantly in the upper abdomen. His abdominal pain had no reference or radiation and there was no jaundice associated with it. The patient had been admitted four times in various hospitals during this period and every time basic laboratory evaluation including liver function tests and serum amylase were within normal limits. His ultrasound examination had been within normal limits on each occasion he was hospitalized for his abdominal pain. The patient denied any high-risk behavior or drug abuse. Over this period he had a stable appetite and constant weight. On examination, he was conscious oriented and he had stable vitals. There was no icterus or lymphadenopathy. His systemic examination was unremarkable. 
Evaluation and course : 
                            Laboratory data revealed normal hemogram, normal liver function tests, and his abdominal ultrasound was also within normal limits. There were no eggs or ova in his stool examination. Keeping in view recurrent biliary colics magnetic resonance cholangiopancreatography (MRCP) was done which showed a doubtful filling defect in the common bile duct but intra-hepatic biliary radicals were not dilated. There were no gall stones and the rest of the viscera were within normal limits. 
Endoscopic retrograde cholangiopancreatography (ERCP) was undertaken which revealed normal papilla. Selective common bile duct (CBD) cannulation was done and cholangiogram revealed a filling defect in the lower end of the common bile duct. There was mild dilatation of the common bile duct (Figure 1  however, biliary radicals were not dilated. 

Fig 1 ERCP showing filling defect in the lower end of CBD 

Sphincterotomy was done and CBD was swept with a biliary balloon and a live Fasciola hepatica was seen coming out of the common bile duct (Figure 2 and Fig 3)

Fig 2 Live Fasciola hepatica removed 

Fig 3 Complete removal of Fasciola hepatica 

                    Later using biopsy forceps the worm was taken out of duodenum and confirmation of the species, Fasciola hepatica was made by the microbiology department of the hospital. The patient was given two tablets of triclabendazole 250 mg (manufactured by Novartis) after the procedure. Following therapeutic ERCP patient became symptom-free and is attending our clinic for the last 24 months now.

Teaching message : 
        Fascioliasis is one of the unusual causes of recurrent biliary colics and it warrants a high degree of clinical suspicion especially in non-endemic areas. The current report emphasizes that ERCP may be considered for the management of recurrent biliary colics even though classical features of biliary obstruction may not be present.

            
For further Reading click the Link:   Fascioliasis

Treat the patient and not an investigation report!

Clinical scenario: A 39-year-old female presented with a CT scan report, that read, " multiple hypodense lesions in the liver suggestive of metastasis liver. The gall bladder, Hepatic veins, portal vein are normal.     No lesion in the CBD and intrahepatic ducts are also normal".
The patient was admitted for evaluation of the primary after explaining poor prognosis to her husband thoroughly.
 On examination, she was conscious, oriented and deeply Jaundiced. Her vitals were stable. Her systemic examination was unremarkable.
 Laboratory tests showed normal hemogram but ESR (erythrocyte sedimentation rate )was raised at 52 mm/H (normal, 0-20 mm/H). She had an elevated INR 2.7 Her liver function tests revealed predominantly conjugated hyperbilirubinemia [Bilirubin 12 mg/dl )] elevated liver enzymes (AST aspartate aminotransferase: 818U/L and ALT 51 5 U/L). Serum alkaline phosphatase levels were also elevated at 327 IU/L /L  All her viral markers were negative.

Fig1 CT scan report hypodense lesions in the liver.

All tumor markers CA -125, CEA and Alpha fetoproteins were elevated. 

For the search of the primary an upper GI endoscopy, colonoscopy including a mamogram was carried out. All turned out to be normal. 

 While the search for the primary was on, day 4th of admission the patient was found to be incoherent, talking irrelevantly. 

Her arterial ammonia levels were high and she was shifted to ICU and managed as hepatic encephalopathy. 

Gladly, her sensorium improved after 3 days and a liver biopsy was planned for evaluation of liver lesions. Keeping in view her high INR 4 units of FFP were transfused and transjugular liver biopsy was done.

 The Liver biopsy was suggestive of Autoimmune hepatitis a great surprise to one and all.

She was given oral steroids and her Liver function tests improved. 

Repeat Ultrasound of the abdomen showed clearance of liver lesions 

Fig 2 USG showing normal  liver 

One year later she was the mother of her 3rd baby.

Take-Home message Focal liver lesions are more often discovered with the widespread use of diagnostic imaging modalities. Despite tremendous advancements in the field of radiology, radiological features are not definite. Treat the patient and not an investigation report.

Staggering waiter !

Clinical scenario 

A 57-year-old male patient, waiter by occupation
without any previous comorbidities,

came with complaints of the frontal
headache of one-week duration

It was associated with, low-grade fever & chills.

The patient also complained of swaying
to the left side while walking

which affected his job in the hotel.

There were no similar complaints in the past,
no history of prior trauma,
head injury, fall or recent vaccination.
No history of seizures.
No history of loss of weight or appetite. 

On examination:
The patient's vitals and general physical
examination were normal.

CNS examination revealed normal higher mental function.

The cranial nerves, motor system, sensory, examination were normal.

The fundus examination was also normal.

He had no signs of meningeal irritation.

However, there was the presence of bilateral cerebellar signs
in the form of ataxia,

dysdiadochokinesia, finger nose ataxia more on
the left side than the right.

The patient had classical cerebellar gait, 

Other system examination was normal.

Evaluation

On evaluation, the patient had normal Complete blood count  

Hb- 14g%, TLC-8000cells/mm3, platelets,
ESR eosinophils we’re in a normal range. 

RBS, LFT, RFT were normal. The serology for  HIV, HBsAg was negative.

MRI brain revealed multifocal ring-enhancing lesions
in supra and infratentorial neuroparenchyma with
diffuse cerebral edema suggestive of neurocysticercosis.

(Fig 1) 

Fig1 Neurocystiscircosis 

CSF fluid analysis showed protein 17 mg%, glucose 91mg%,
cell count of 18  with neutrophil predominance.
CSF ADA was within normal limits.

The ZN stain of CSF was negative for AFB.

Hospital course:

His GCS at presentation was 15.
The patient was Treated with anti-edema measures  
Mannitol, dexamethasone 8 mg thrice a day.

However during the course of hospital stay
patient had a drop in GCS to E4M5V4, 

Fig 3 Neurocystiscircosis cerebellum region 

CT brain was done showed obstructive hydrocephalus
and a ventriculoperitoneal shunt

was placed to decompress the brain.

On Post-op day 3 patient's sensorium improved  and

he was discharged home a few days later

Teaching message 

Bilateral cerebellar signs are more common with systemic diseases

like post-infectious cerebellitis, multiple sclerosis,
ADEM.

But in tropical areas, parasitic infestation should also
be considered

as a differential for acute ataxia.

Acute ataxia is an uncommon presentation of neurocysticercosis.

Click to read further  

Diagnosis and Treatment of Neurocysticercosis

This case was contributed by

Dr.Shruthi S

Asst.Prof,

Dept of General Medicine Yenepoya Medical College Mangalore Karnataka

Back to School

Friends: Previously we used to read A for Apple and now

A... Anorexia, anemia, asthenia... R/O Ca stomach

B...Bloating in young may be IBS R/O...organic cause in elderly

C....Courvisors law..in a jaundiced patient if the gall bladder is palpable it is usually due to extrahepatic malignancy exceptions double .....impaction of stones in CBD &cystic duct, oriental colangiohepatitis

D.....Diarrhea may be IBS in young but evaluate before you label a person IBS R/O microscopic

colitis, celiac disease,

E...ECG Changes ....never forget pancreatitis could be a cause.

F.....Fatigue ...R /o gut malignancy, chronic hepatitis, Autoimmunity or Tuberculosis

G...Glossitis R/O iron, folate B 12 deficiency

H...Hematochezia ....R/O UGI source

I.....Irish nodule (left axillary lymph node)...R/O ca stomach

J....Jaundice.... Always evaluate .viral hepatitis, drugs etc R/O ......Biliary obstruction &

autoimmune hepatitis, etc

K....Koilonychia...r/o Evaluate cause of iron deficiency, colon malignancy in men

L ...Large joint arthritis .R/O Inflammatory bowel disease, hepatitis

M...Melena ...always evaluate don’t miss right sided colon growth

N....Nausea...drug induced r/o pregnancy in the childbearing female.

O...Oral pigmentation .... Peutz.Jeghers to be ruled out

P...Psoas sign.... positive in appendicitis

Q...Quality of life is disturbed more than any complication in IBS

R....Regurgitation likely reflux, psychogenic, r/o organic cause.

S...Sister Joseph nodule ...r/o internal malignancy

T...Trousseaus sign..migratory thrombophilibitis ...r/o ca pancreas

U....Uveitis R/O Inflammatory bowel disease

V...Virchow node palpable R/O internal malignancy

W...Water brash...Gastro esophagial reflux

X....Xanthomas ..R/O Lipid abnormalities

Y....Yellow nail patella syndrome

Z.....Zollinger Ellison syndrome...

Careful examination clinched the diagnosis

Clinical scenario:
A 45-year-old farmer, presented with complaints of fever, chills, generalized weakness associated with yellowish discoloration of sclera for 15 days.
On examination: His vitals were unremarkable, he was febrile at the time of presentation and had Jaundice. Systemic examination revealed hepatosplenomegaly.

Investigations
Hb 12 .3 gm/dl Plt 1 lakh,
Bilirubin 5.4mg/dl
SGOT/SGPT - 160/174, Alp 352, D.
An ultrasound revealed hypoechoic lesions in segment VII and VIII of the liver and also in the spleen ? Metastasis
Later CECT was done which showed - hepatosplenomegaly with hypoechoic lesions in spleen s/o infarct as shown in Fig1 and Fig 2

Fig.1    Splenic infarcts  

Fig2 Splenic infarct 

However, a careful examination of the skin revealed an eschar Fig 3 on the right lateral aspect of the abdomen in the lumbar quadrant.

Fig3 Eschar in the skin  

Further test showed Scrub Ig M 3.52 (positive)

Hospital course

Pt received oral doxycycline following which his symptoms improved. He was discharged and advised to follow up after a month.

Teaching message

Splenic infarcts, commonly seen in brucellosis and melioidosis, can also be seen in scrub typhus as well.

Click here to Read Further

This case was contributed by

Dr.Rohit Rajeevan,

Asst.Prof,

Dept of General Medicine

Old man with fever and altered sensorium !

Clinical scenario :

A 60-year-old male presented with complaints of easy fatigability of 3 months duration .it was followed by a fever of 3 weeks duration

Fever was not associated with Rigors and Chills more so in the evenings.

The patient also complained of reduced appetite and weight loss-16kgs in 3 months. Before the current presentation, he developed progressive deterioration in his sensorium and vomiting. The vomiting was not bilious, not blood-tinged usually the food taken by him earlier.

There was no history  of   cough with expectoration, no history of diarrhea, no dysphagia

No history of diabetes, hypertension in the past or any other comorbidity

On examination:

The patient was irritable and disoriented to time, place and person

Pallor was present

Generalised emaciation,BMI – 18.2kg/m2

No icterus, clubbing, cyanosis, pedal edema, lymphadenopathy

Pulse rate- 100 bpm – Regular Rhythm

BP- 110/90 mmHg

RR- 23 cycles per minute

Found to have polyuria during input-output monitoring

RS: No accessory muscles used, B/L Reduced breath sounds at base of the lung

P/A : Umbilicus appears normal, distended abdomen, No organomegaly,

and bowel sounds heard,

On Percussion – Shifting Dullness (+)

CNS: No focal neurological deficit

Differential diagnosis considered were :

Chronic Infections-Tuberculosis/HIV

Malignancy-hematological/gastrointestinal/lung

Endocrine-diabetes, hyperthyroidism, hyperparathyroidism

INVESTIGATIONS 

CBC-Hb-9.4 g/dL ,TLC 5.5 X 103  /µL,Neutrophil-79.6% (25-50%)

Lymphocyte 12.8% (25-40%)Eosinophil 1.8% (1-6%)Basophil0.4% (0-1%)

Monocyte5.4% (1-8%)

Blood sugars-normal, TSH-normal

Blood urea level -75mg/dL (15-36g/dL),Serum Creatinine-3.1mg/dL (0.6-1.2mg/dL),

Serum Calcium-14.0mg/dL (8.4-10.2mg/dL),Serum Albumin-3.2 g/dL (3.2-4.4g/dL),

Corrected Calcium level-14.64mg/dL (8.5-10.2mg/dL),CRP-23.4mg/L (<10mg/L),

Serum phosphate-2.5mg/dL (2.5-4.5mg/dL),Serum ACE Levels-Normal,

Parathyroid hormone (PTH)-1.60pg/mL   (15-68.3pg/mL)

Vitamin D-45ng/mL (20-50ng/mL)

Chest X-ray shows mild blunting of costophrenic angle
(image enclosed)

USG Neck-Thyroid gland appears normal in size and texture.

No evidence of enlarged Parathyroid glands. No other significant abnormality detected

CECT Thorax and abdomen-Image shows pleural thickening with enhancement

(costal, mediastinal and diaphragmatic pleura).

Above findings give  a differential diagnosis of Koch’s Disease or

 Mesothelioma to be considered and suggested pleural biopsy(image enclosed)

Histopathology of pleura(CT guided pleural biopsy)-

Section studied show thickened pleura with numerous granuloma composed of epithelioid cells,

Langhan’s giant cells and few lymphocytes-features are suggestive of tuberculosis of pleura

Final diagnosis- Granulomatous hypercalcemia secondary to disseminated tuberculosis

HOSPITAL COURSE 

Differential diagnosis considered were: Chronic Infections-Tuberculosis/HIV, Malignancy-

hematological/gastrointestinal/lung, Endocrine-diabetes, hyperthyroidism, hyperparathyroidism.

On evaluation found to have severe hypercalcemia with acute kidney injury. 
His altered sensorium and polyuria were also explained by hypercalcemia.

Such severe hypercalcemia usually occurs with malignancy. He was hyper hydrated with IV fluids.

Calcitonin, furosemide, and steroids were given after correction of dehydration.

Acute kidney injury resolved and calcium levels reduced.

His Thyroid,  PTH levels were normal.

CECT thorax and abdomen was done to screen any internal malignancy /tuberculosis/sarcoidosis

which showed pleural thickening which was biopsied.

Biopsy revealed granuloma with caseous necrosis.

ATT was started. Tapering dose of steroids were given for 4 weeks to control hypercalcemia

as it was granuloma induced hypercalcemia.  The patient improved symptomatically, polyuria resolved,

sensorium normalized.

He gained weight of 4 kg at follow up and calcium levels were 8.5mg/dl.

TEACHING MESSAGE 

Though severe hypercalcemia more than 12mg/dl is commonly seen in malignancy and

 hyperparathyroidism reversible causes like granuloma induced hypercalcemia should be

 considered in a case of Pyrexia of unknown origin. Severe hypercalcemia being

one of medical emergency aggressive hydration and treatment of the primary cause

in our patient-led to complete reversal of his AKI, hypercalcemia, and resolution of PUO   

This case was contributed by 

Dr.Balachandra S Bhat,

Assistant Professor,

Dept of General Medicine, Yenepoya Medical College