Jessica Higgs, MD
Bradley University
ACHA Annual Meeting
Boston, June 1, 2013
MEDICAL GRAND ROUNDS
LEARNING OBJECTIVES
Identify how to approach difficult unknown
case presentations
 List differential diagnoses for unknown case
presentations
 Describe common pitfalls in the approach to
difficult cases

Hematology
CASE 1
VISIT #1
20 yo AAF presents to the clinic for evaluation
of lump in left armpit
 States initially noticed lump 6 weeks ago and
at that time it was painful
 Returned a few days ago but not painful and
seems to be getting smaller
 No rashes or other lesions noted
 No other complaints

VISIT #1

Exam
 Vitals
– BP 108/60, P 80, Temp 98.9, R 12
 NAD
 Left
armpit – palpable firm elongated nodule,
movable, nontender
 Anterior cervical, posterior cervical, right axilla,
groin exam negative for further enlarged lymph
nodes
VISIT #2
Patient returns 1 week later
 States size has been fluctuant over last week
 Has become painful again
 Complains of fatigue, cold symptoms, loss of
appetite, headaches

VISIT #2

Exam
 Vitals
– BP 120/70, P 68, T 97.3
 CV – RRR, no murmurs
 Resp – CTA Bilaterally
 Left axilla – mobile, nonerythematous, no warmth,
slightly larger than previous exam
 No other lymph nodes palpable
VISIT #2

Exam
 Vitals
– BP 120/70, P 68, T 97.3
 Left axilla – mobile, nonerythematous, no warmth,
slightly larger than previous exam
 No other lymph nodes palpable

Labs
 CBC
 ESR
 mono
VISIT #3
F/U 1 week later
 Thinks lymph node may be smaller again
otherwise no change in symptoms
 CBC

 WBC
3.6 Neutrophils – 33, Lymphocytes – 53,
Monocytes - 14
ESR - 30
 Mono - negative

VISIT #3

Exam
 Vitals
– P 72, T97, R 14
 Left axilla – 5mm x 2mm firm mobile lesion
 Shotty lymph nodes anterior cervical area and right
groin
VISIT #3

Exam
 Vitals
– P 72, T97, R 14
 Left axilla – 5mm x 2mm firm mobile lesion
 Shotty lymph nodes anterior cervical area and right
groin

Labs
 CRP
 LDH
VISIT #4
F/U 2 days later for labwork
 CRP – 1.43
 LDH – 853

VISIT #4
F/U 2 days later for labwork
 CRP – 1.43
 LDH – 853
 Patient does not have insurance coverage
outside of home area

 Sent
home for CXR and lymph node biopsy
DIAGNOSIS????
KIKUCHI DISEASE
KIKUCHI DISEASE
Rare, benign condition of unknown cause
 Characterized by cervical lymphadenopathy
and fever in previously well individual
 Women are more common than men and most
patients younger than 40
 Most frequently reported in Asia, but found in
all racial and ethnic groups
 Some similarities to SLE

Richards, M. Kikuchi’s disease. UpToDate 2013
KIKUCHI DISEASE

Differential diagnosis
 Lymphoma
 Tuberculous
adenitis
 Lymphogranuloma venereum
 Kawasaki disease
Richards, M. Kikuchi’s disease. UpToDate 2013
KIKUCHI DISEASE

Clinical symptoms include:











Low grade fever
Lymphadenopathy, most commonly cervical and localized
Fatigue
Joint pain
Rash
Arthritis
Hepatosplenomegaly
Night sweats
Nausea/ vomting
Weight loss
Labs

Leukopenia in 30%, ESR elevation in up to 70%
Richards, M. Kikuchi’s disease. UpToDate 2013
KIKUCHI DISEASE

Diagnosis made by lymph node biopsy
 Paracortical
foci often with necrosis and histiocystic
cellular infiltrate
No effective treatment known, symptoms
usually resolve within one to four months
 Recurrences have been reported and can
develop SLE

Richards, M. Kikuchi’s disease. UpToDate 2013
Gastroenterology
CASE 2
VISIT #1
22 yo WM presents to the clinic for abdominal
pain
 Right sided pain for 16 hours
 No fevers or chills, no nausea, vomiting,
diarrhea or constipation
 Decreased appetite but drinking fluids

VISIT #1

Exam
 Vitals
– BP 120/80, T 98.1, P – 80, R – 12
 NAD
 Abdomen
– soft, +tenderness without distension,
Negative Murphy’s, McBurney’s, rebound
 Positive right CVA tenderness
VISIT #1

Exam
 Vitals
– BP 120/80, T 98.1, P – 80, R – 12
 NAD
 Abdomen
– soft, +tenderness without distension,
Negative Murphy’s, McBurney’s, rebound
 Positive right CVA tenderness

Labs
 CBC
 UA
VISIT #2
F/U the following day
 Right sided abdominal pain getting worse, now
rates 7/10
 Constant sharp pain with radiation to back
 Anorexia and mild nausea
 Pain with walking
 No constipation or diarrhea

VISIT #2

Exam
 Vitals
– BP 122/80, T 98.3, P 96, R 12
 +tenderness right side, +McBurney, +rebound,
+guarding
 Negative murphy, psoas, obturator signs
VISIT #2

Exam
Vitals – BP 122/80, T 98.3, P 96, R 12
 +tenderness right side, +McBurney, +rebound,
+guarding
 -murphy, psoas, obturator


Lab
CT scan of abdomen
 CBC
 CMP

DIAGNOSIS???????
SEGMENTAL INFARCTION OF THE GREATER
OMENTUM
SEGMENTAL INFARCTION
Described over 100 years ago
 Etiology unknown
 90% present with right-sided abdominal pain
 Males more frequently affected
 Occurs mainly in 4-5th decade although a
significant proportion of cases described in
pediatric population as well

Epstein, L, Lempke, R. Annals of Surgery, 1968
SEGMENTAL INFARCTION

Differential Diagnosis
 Appendicitis
 Cholecystitis
 diverticulitis
Soobrah, R, et al. Case Reports on Medicine, 2010
SEGMENTAL INFARCTION
Incidence estimated to be around 0.1% of all
laparotomies performed for acute abdomen
 Predisposing factors may include

 Obesity
 Trauma
Recent abdominal surgery
 Postprandial vascular congestion
 Sudden increase in intra-abdominal pressure
 Hypercoagulability

Soobrah, R, et al. Case Reports on Medicine, 2010
SEGMENTAL INFARCTION

Clinical findings include
 acute
or subacute abdominal pain
 temperature normal to slightly raised
 localized tenderness with varying degree of
guarding on right side of abdomen
 Nausea, vomiting, anorexia and diarrhea are rare
 WBC and CRP may be elevated
CT or ultrasound can make diagnosis
 Management either conservative or surgical

Soobrah, R, et al. Case Reports on Medicine, 2010
Oncology
CASE 3
VISIT #1
20 yo WF presents to clinic for lump on side of
trunk
 Unsure how long it has been there, feels hard
to touch, slightly painful, not red
 No other complaints

VISIT #1

Exam
 Vitals
BP 104/76, P 68, T 97.2, wt. 130 lbs
 Right chest – 1cm smooth somewhat firm mobile
mass overlying right lateral lowest rib
 nontender
VISIT #1

Exam
 Vitals
BP 104/76, P 68, T 97.2, wt. 130 lbs
 Right chest – 1cm smooth somewhat firm mobile
mass overlying right lateral lowest rib
 nontender

Labs
 CXR
with right rib views
VISIT #2
F/U 1 week later
 CXR with rib views – negative
 States lump is still there but not painful
anymore

VISIT #2

Exam
 10th
rib

Plan?
rib – soft tissue mass, firm, mobile over top of
VISIT #3
3 months later
 Returns to clinic for recheck of cyst on right
side
 States has doubled in size in last 4 days
 Now very painful, even without palpation, kept
awake last night
 Denies fevers, weight changes, cold symptoms,
N/V/D

VISIT #3

Exam
 Vitals
BP102/70, P 68, T 97.6, wt. 131
 Right rib cage – 2inch x 2inch round, firm fixed,
raised lesion extending from rib along midaxillary
line, no erythema, nontender
 Remainder of exam - WNL
VISIT #3

Exam




Vitals BP102/70, P 68, T 97.6, wt. 131
Right rib cage – 2inch x 2inch round, firm fixed, raised lesion
extending from rib along midaxillary line, no erythema, nontender
Remainder of exam - WNL
Labs





MRI
CBC
LDH
ESR
Uric Acid
DIAGNOSIS???
EWING SARCOMA
EWING SARCOMA






Highly malignant tumor occurring in adolescents and
young adults ages 10-25
Can develop in almost any bone or soft tissue but most
common in pelvis, axial skeleton, and femur
Overt metastatic disease present in less than 25% at
time of diagnosis but assumed present due to 80-90%
relapse rate if treated locally
Typically present with pain or swelling of a few weeks or
months of duration
Aggravated by exercise and worse at night
Fever, fatigue, weight loss, or anemia are present in 1020% of cases
Clark, et all. NEJM, 2005
EWING SARCOMA

Labwork
 CBC
 CMP
 LDH

Imaging
 Radiographs
 CT
scan
DeLaney, et al. UpToDate, 2013.
EWING SARCOMA

Differential Diagnosis
 Subacute
osteomyelitis
 Eosinophilic granuloma
 Giant cell tumor
 Osteosarcoma
 Neuroblastoma
 Acute leukemia
 Fibrous histiocytoma
 Primary lymphoma of bone
DeLaney, et al. UpToDate, 2013
EWING SARCOMA

Prognostic Factors
 Disease
extent
 Tumor site and size
 Response to therapy
 Age
 Molecular findings
DeLaney, et al. UpToDate, 2013
Cardiology
CASE 4
VISIT #1
21 yo HF presents to clinic for pain and numbness
in left hand
 Seen by ortho over recent break and diagnosed
with ulnar nerve issue and given course of steroids
that has completed and Lyrica
 Problem initially started about 1 month ago
 Left wrist and hand intermittently turn bluish in
color and cold. Happens when goes outside but
can happen anytime
 Very painful, denies burning sensation

VISIT #1

Exam



Vitals BP 110/80, P 72, T 98.3
Patient is tearful
CV




MSK




Allen test positive, refill ulnar artery 15 sec, radial artery 10 sec
hand is cool to touch with pallor
Heart RRR, no murmurs
Decreased grip strength left hand with reduction in wrist ROM due to pain
FROM of neck with no change in pain with neck extended and turned to left
No change in pain with shoulder movement
Neuro

Tinels and Phalens positive left hand
VISIT #1

Exam



Vitals BP 110/80, P 72, T 98.3
Patient is tearful
CV




MSK




Decreased grip strength left hand with reduction in wrist ROM due to pain
FROM of neck with no change in pain with neck extended and turned to left
No change in pain with shoulder movement
Neuro


Allen test positive, refill ulnar artery 15 sec, radial artery 10 sec
hand is cool to touch with pallor
Heart RRR, no murmurs
Tinels and Phalens positive left hand
Labs


Dopplar studies
CXR
INTERIM

Dopplar studies
 No
arterial flow seen in left fingers. Findings raise
concern for vasospasm. Small vessel disease or
emboli considered less likely
 Upper extremity WNL

CXR
 Hypoplastic
second rib
left first rib with thickened anterior left
INTERIM

Dopplar studies



CXR


Hypoplastic left first rib with thickened anterior left second rib
Labwork


No arterial flow seen in left fingers. Findings raise concern for
vasospasm. Small vessel disease or emboli considered less likely
Upper extremity WNL
ANA, ESR, CRP, RA factor, phospholipid antibiodies, CBC, PT, PTT,
lupus
Plan

Norvasc for vasospasm and vicodin for pain
VISIT #2
F/U 3 days later
 Norvasc is helpful, pain medicine somewhat
helpful, keeping hand warm
 Complains of dizziness
 Labwork negative except for elevated CRP

VISIT #2

Exam
 Vitals
– BP 112/80, P 88
 Left hand – Pulse palpable, hand is cool compared
to right but not cold, no pallor
VISIT #2

Exam
 Vitals
– BP 112/80, P 88
 Left hand – Pulse palpable, hand is cool compared
to right but not cold, no pallor

Plan
 Increase
norvasc
 Referral to vascular
DIAGNOSIS?????
THORACIC OUTLET SYNDROME
THORACIC OUTLET SYNDROME
Refers to a constellation of signs and
symptoms that arise from compression of the
neurovascular bundle by various structures in
the area just above the first rib and behind the
clavicle
 Neurogenic, Venous, or Arterial
 Anatomy

 Scalene
triangle and first rib
Goshima, White. UpToDate, 2013.
THORACIC OUTLET SYNDROME

Pathogenesis
Anomalous ribs
 Muscular anomalies
 Injury


Clinical Exam
Adson’s test – of little clinical value
 Wright’s test
 Allen test
 Hand wasting
 Arterial – pain, pallor, paresthesia, and coldness

 Pulses,
bruits
Goshima, White. UpToDate. 2013
THORACIC OUTLET SYNDROME

Differential Diagnosis
 Neurogenic
 Vascular
 Raynouds
phenomenon
 Shoulder injury
Goshima, White. UpToDate, 2013.
THORACIC OUTLET SYNDROME

Imaging
 Radiographs
 Duplex
ultrasound
 CT/MRI

Surgery
Goshima, White. UpToDate, 2013.
Gynecology
CASE 5
VISIT #1
27 yo WF presents to clinic complaining of weight
gain over past 6 months
 Complains of abdominal distension and occasional
side pains
 Irregular periods
 Denies sexual activity
 PMH significant for PCOS, taking metformin
 FMH significant for ovarian CA and fibroid tumors

VISIT #1

Exam
 Vitals
– BP 176/88, P 76, T 97.6, wt. 257lbs
 Anxious appearing
 Abdomen – firm, BS present, non tender
 Gyne – unable to discernably palpate uterus or
ovaries due to large mass
VISIT #1

Exam
Vitals – BP 176/88, P 76, T 97.6, wt. 257lbs
 Anxious appearing
 Abdomen – firm, BS present, non tender
 Gyne – unable to discernably palpate uterus or ovaries
due to large mass


Labwork
Pregnancy test – negative
 CBC, CMP, ESR, CRP
 sonogram

INTERIM

Labwork
CRP – 1.97
 CBC, ESR, CMP - WNL


Imaging
Sonogram – large cystic mass occupying the abdominal
and pelvic cavity extending from the epigastric to the
pubic symphysis. Recommend CT
 CT scan – 24 x 34 x 36 cm ovarian cyst

DIANGOSIS???
GIANT CYSTADENOMA
MUCINOUS CYSTADENOMA
Adnexal mass may be found in females of all
ages
 Prevalence in women age 25-40 is around7.8%
 Risk of malignancy is higher in prepubescent or
postmenopausal females

Hoffmann. UpToDate, 2013.
MUCINOUS CYSTADENOMA

Differential Diagnosis
 Physiologic/functional
cysts
 Polycystic ovary syndrome
 Pregnancy related etiology
 Inflammatory
 Benign ovarian neoplasm
 Malignant ovarian neoplasm
Hoffmann, UpToDate, 2013.
MUCINOUS CYSTADENOMA
Ovarian neoplasm arise from surface
epithelium, germ cells, and sex-cord-stromal
tissue
 Persist unless excised
 Most common benign ovarian masses

 Serous
or mucinous cystadenoma
 Endometrioma
 Mature cystic teratoma
Hoffmann. UpToDate, 2013.
Genetics
CASE 6
VISIT #1
19 yo WF Div. I softball player presents to
training room with repeated cramping
 Cramping occurs irregardless of heat or
hydration status
 Occurs predominantly in right arm, but does
occur in left arm occasionally and bilateral
thighs and calves as well
 Diagnosed with rhabdomyolysis last year at
community college

VISIT #1

Exam
 Vitals
 Well
appearing female
 CV – RRR, no murmurs
 MSK - WNL
VISIT #1

Exam
 Vitals
 Well
appearing female
 CV – RRR, no murmurs
 MSK - WNL

Labs
 CMP,
CK, UA, TSH
FOLLOW-UP
CK – 4254
 CBC – WNL
 UA – unremarkable
 CMP – WNL

DIFFERENTIAL???
FURTHER FOLLOW-UP
CK ranges from 101-9131
 Muscle biopsy

 Histology
showed myophosphorylase stain with
large number of markedly pale fibers with no
staining and peripheral fibers normally staining
 Deficiency of phosphofructokinase activity
DIAGNOSIS?????
GLYCOGEN STORAGE DISORDER
GYLCOGEN STORAGE DISORDER

Differential Diagnosis
 Rhabdomyolysis
 Polymyositis
 Electrolyte
 Trauma
 Infection
 Drug
Use
abnormalities
GLYCOGEN STORAGE DISORDER
A number of inborn errors of glycogen
metabolism
 Major manifestations of disorders of glycogen
metabolism affecting muscle are muscle
cramps, exercise intolerance and easy
fatigability, and progressive weakness
 Focus on Type V – McArdle’s syndrome

Darras, Craigen. UpToDate, 2013
MCARDLE’S SYNDROME
Autosomal recessive
 Presents in adolescence or early adulthood
with exercise intolerance, fatigue, myalgia,
cramps, myoglobinuria, poor endurance,
muscle swelling, and fixed weakness
 Forearm muscle exercise testing
 Muscle biopsy with biochemical or
histochemical analysis

Darras, Craigen. UpToDate, 2013
Sports Medicine
CASE 7
VISIT #1
20 yo AAM soccer player presents after game
with right knee pain
 Slide tackling another player felt like left knee
twisted
 Tenderness over lateral aspect of knee with
slight increase in opening with varus stress
compared to left
 Diagnosed with grade 1 LCL sprain and told to
ice

VISIT #2
Presents to training room following day
 States knee is feeling much better but now
having trouble lifting his right foot
 Put ice on after the game and then went to sign
autographs after kids clinic. Left ice on leg for
at least 45 minutes
 Denies pain in leg

VISIT #2

Exam
General – NAD, patient of slight build
 Right leg – no swelling, erythema, warmth, or
tenderness to palpation. Patient has difficulty
differentiating sharp and dull sensation over lateral
aspect of leg
 Right knee – No tenderness to LCL, still slight opening
with varus stress
 Right foot – unable to dorsiflex foot, weakness in
eversion, remainder of movement intact

DIAGNOSIS?????
PERONEAL NERVE INJURY
PERONEAL NERVE INJURY
Most frequent site of injury is just below knee
as nerve wraps around lateral aspect of the
fibula
 Typical presentation is acute foot drop,
parathesias over dorsum of foot and lateral
shin
 Exam shows weakness in dorsiflexion and
eversion, sensory deficit at dorsum of foot and
lateral shin

Rutkove, UpToDate, 2013
PERONEAL NERVE INJURY
No effective treatment
 Those presenting with complete lesions, while
mildly preserved strength recover fully

Rutkove, UpToDate, 2013
Psychiatry
CASE 8
INITIAL CONTACT
Faculty member calls counseling center
 Concern for student who just finished a test
 Reports no previous issues with this student
 States “I can’t describe it. I will bring you the
test.”

DIFFERENTIAL?????
PSYCHOTIC BREAK
QUESTIONS??
THANK YOU
REFERENCES
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
Bladt, O, et al. Mucinous Cystadenoma of the Ovary. JBR-BTR, 2004.
Clark, et al. Soft-Tissue Sarcomas in Adults. NEJM, 2005
Darras, Craigen. Muscle phosphorylase deficiency (glycogen storage disease V,
McArdle disease) UpToDate, 2013
DeLaney, et al. Clinical presentation, staging, and prognostic factors of the Ewing
sarcoma family of tumors. UpToDate, 2013
Epstein, L, Lempke, R. Primary Idiopathic Segmental Infraction of the Greater
Omentum. Annals of Surgery, 1968
Hoffmann. Differential Diagnosis of adnexal mass. UpToDate, 2013.
Goshima, White. Overview of thoracic outlet syndrome. UpToDate, 2013
Richards, M. Kikuchi’s disease. UpToDate 2013
Rutkove, Overview of lower extremity peripheral nerve syndromes. UpToDate, 2013
Soobrah, R, et al. Conservative Management of Segmental Infarction of the Greater
Omentum: a Case Report and Review of the Literature.Case Reports on Medicine,
2010