Clinical Pearls. Dr. Muhammad Jamal Uddin. Resident, Internal Medicine BSMMU

Transcription

1 Clinical Pearls Dr. Muhammad Jamal Uddin Resident, Internal Medicine BSMMU

2 A 55-Year-Old Woman with CKD and Recurrent Unconsciousness

3 PARTICULARS Mrs. X 55 years Muslim House wife Dhaka

4 BACK GROUND HISTORY HTN- 35 Years Hypothyroidism- 25 Years DM -13 Years CKD -12 Years

5 March 2015 Developed neck pain and low grade fever for 3 months Initially treated with physiotherapy Evaluated by a neurologist

6 CBC: Hb 10.1 g/dl, ESR 50 mm in 1 st hour TC 6300/mm 3, N 605%, L 35%, M 03%, E 02% S. Creatinine 6.03 mg/dl

7 X-ray Cervical Spine B/V FINDINGS: Cervical curvature is exaggerated Compression collapse with anterior wedging of C5 Degenerative change Disc space reduction in between C4 & C5 vertebra IMPRESSION: Cervical spondylosis with compression collapse of C5 vertebra

8 MRI of Cervical Spines IMPRESSION: Collapse of C5 spine & marrow replacement at C4 & C5 Paraspinal granulation tissue and mild cord compression & compression on C5, C6 & C7 bilateral exiting nerve roots

9 Was diagnosed as a case of Pott s disease of cervical spine In BSMMU Anti-TB started on 23/03/2015 Rimstar 2FDC PZA 500 mg Ethambutol 400 mg Prednisolone 20 mg Planned for anterior decompression with fixation

10 26/03/15 : Became unconscious Blood Urea 218 mg/dl S.Creatinine 7.0 mg/dl RBS 6.2 mmol/l S.Electrolyte Na+ 148 mmol/l K mmol/l Cl mmol/l

11 Shifted to ICU on 26/03/15 night GCS 5/15, Vitals : Normal Plantar B/L flexor, Sign s of meningism : Absent

12 CBC : Hb 12.5 gm/dl, ESR 98 mm in 1 st hour TC 10,600/cmm, N 80%, L 13%,M 05%, E 02% S.Creatinine 7.2 mg/dl S.Urea 211 mg/dl SGPT 18 U/L S.Calcium 7.3 mg/dl, S.Albumin 3.7 gm/dl RBS 6.7 mmol/l

13 ABG : Metabolic Acidosis USG of W/A: Chronic renal parenchymal disease Anti-TB stopped on 27/03/15 Shifted to BSMMU for dialysis

14 BSMMU on 29/03/15 S.Creatinine 7.2 mg/dl LFT : Normal Urine R/E Bilirubin(T) 10.8 micromol/l Total Protein 83 gm/l, S.Albumin 38 mmol/l ALT 54 U/L (N: 30-65) Sp. Gravity 1.010, PH 7.0, Protein +++, Sugar + Pus Cell 1-2, RBC 4-8/HPF

15 ACTH pg/ml ( N: ) Basal Cortisol mmol/l (N: ) RBS 5.6 mmol/l, HbA1C 6.1% Gamma-GT 25U/L (N: Up to 39 U/L) Magnesium 0.9 mmol/l HBsAg & Anti HCV -ve

16 Protein Electrophoresis : Normal MT : 12 mm S.PO4 4.2, S.Uric Acid 4.2 TSH 3.18, F.T CXR : Normal ECG : Sinus Tachycardia

17 1 st session HD given through Rt. Femoral venous catheter on 29/3/15 Total 3 session HD given

18 30/3/15 02/4/15 04/4/15 09/4/15 11/4/15 Urea Creatinine Pt regained consciousness on 05/4/15

19 On 06/04/15 anti-tb drugs re-started Tab. Rimstar 2FDC Tab. PZA 500 mg Tab. Ethambutol 400 mg Tab. Prednisolone 20 mg Was discharged on 12/04/15 & advised to F/U after 01 month

20 Pt developed anorexia & excessive sleepiness on 13/5/15

21 On 16/5/15 admitted in DMCH Anorexia, sleepy & refusal to take food for 3 days Breathlessness & altered mental status for 1 day Appearance : Pale, puffy face Anaemia : ++ Oedema : + GCS : 8/15 Planter : Flexor

22 CBC: Hb-10.0 gm/dl, MCV 89.3fl TC- 9000/mm 3, N 83, L 14, M 02, E 01 RBC /mm 3, TPC /mm 3 Urine R/E: Sp.Gravity 1.008, PH 5.5 Protein ++, Sugar Nil, Pus Cell 7-16, E.Cell 5-12, RBC 1-4/HPF, Granular Cast +

23 S. Creatinine 6.26 mg/dl S. Electrolytes Na mmol/l K+ 4.4 mmol/l Cl mmol/l CO mmol/l RBS 8.3 mmol/l

24 Inj. Sodibicarb & Frusemide along with previous treatment 1 session HD given through JVC on 17/04/15 Next day: GCS 8/15, P 78b/min, BP 120/70 mm of Hg Temp. Normal, Urine output 200 ml Shifted BIRDEM

25 ICU, BIRDEM Anaemia +, Dehydration +, Cyanosis -, P 78 b/min, BP 90/60 mm Hg, RR 20 br/min Temp:98.8 o F GCS 8/15 ( E1 M4 V3)

26 CBC: Hb 7.9 g/dl, RBC /cmm TC 5000/cmm, N 70.8, L 19.4, M 9.1 S. Creatinine 9.5 mg/dl Urea 225 mg/dl S. Electrolytes Na+ 145 mmol/l, K+ 3.2 mmol/l Cl- 107 mmol/l, CO2 26 mmol/l

27 ABG - Metabolic Acidosis Blood for C/S: No growth Urine for C/S: Growth E.Coli( ESBL +ve) 1x10 5 Sensitive to Imipenem, Gentamicin, amikacin, Nitrofurantoin, Netilmicin

28 LFT: Normal S. Ammonia : 18 micro mol/l (Normal) RBS 6.2 mmol/l S. Calcium 8.3 mg/dl, S. Albumin 34.4 gm/dl S. Phos (Inorg) 8.7 mg/dl S. Mg mmol/l

29 Troponin- I: 0.76 CXR - Normal S. CA-125: 9.1 U/ml ( N: < 35.0)

30 One session HD given through Rt. Femoral venous catheter on 18/5/15 18/5/15 19/5/15 22/5/15 23/5/15 S. Urea S. Creatinine (mg/dl)

31 Anti- TB stopped on 19/5/15 Conscious level improving ( GCS 8 to 12 ) Pt transferred to Internal Medicine department, BIRDEM on 23/5/15 evening

32 Shifted BSMMU on 24/5/15 Pt was drowsy, GCS 12/15 S. Urea 116 mg/dl S. Creatinine 5.8 S. Na mmol/l S.K mmol/l S. Cl mmol/l

33 Urea Creatini ne 25/5/15 26/5/15 27/5/15 30/5/15 31/5/15 02/6/15 09/6/ HD HD 1 HD 2 Blood transfusion given on 26/6/15 & 06/6/15 Pt was well oriented on 03/6/15

34 CT Guided FNAC from C5 body (12/6/15) COMMENTS: Mostly necrotic debris few polymorphs, lymphocytes, histiocytes Occasional epithelioid cells Caseation necrosis No malignant cell Dx: Granulomatous inflammation, tubercular

35 Anti-TB started on 16/6/15 Developed altered mental status on 21/6/15

36 Why recurrent unconsciousness?

37

38 CLINICAL DIAGNOSIS Uremic encephalopathy Hepatic encephalopathy TB meningoencephalitis Septicaemia

39 ON EXAMINATION GCS 10/15 Anaemia ++ Temp: F Pulse 92b/min BP: 110/60 mm of Hg, No postural drop Kernig s sign ve Plantar : bilaterally flexor Fundoscope:Grade II hypertensive retinopathy Other systems : No abnormality

40 INVESTIGATIONS CSF study : Normal Short synacthen test: At 9:25 am ACTH 50.7 pg/ml ( N: ND to 46 pg/ml) Cortisol nmol/l At 10:00am Cortisol nmol/l (N: nmol/l) S.Creatinine 5.8 mg/dl

41 MRI OF BRAIN Normal study

42 On 16/6/15: INH 100 mg started 1+0+0>2+0+0>3+0+0 : continue On 20/6/15: Ethambutol 400 mg started ½+0+0: 2 days, then 1+0+0: continue On 21/6/15: PZA 500 mg started 1+0+0>2+0+0>3+0+0: continue & Prednisolone 20 mg 1½+0+0: continue Hold on 24/6/15 Omitted on 21/6/15 Hold on 24/6/15

43 16/6/1 5 21/6/1 5 23/6/1 5 24/6/1 5 25/6/1 5 Urea Creatini ne 27/6/ HD HD 3 HD 4 Altered mental status 01/7/1 5 A-V Fistula constructed in left upper forearm on 02/7/15

44 Can it be INH induced encephalopathy???

45 On 25/6/15: PZA 500 mg 1+0+0: 1 day, then 2+0+0: continue Pt was well oriented on 27/6/15 On 11/7/15: Rifampicin 600 mg On 26/7/15:Ethambutol 400 mg Prednisolone 10 mg 2+1+0

46 09/7/1 5 12/7/1 5 23/7/1 5 03/8/1 5 16/8/1 5 Urea Creatini ne SGPT 25 SGPT 26 Cortisol nmol/l Anti-TB regimen without INH started on 26/07/15

47 FINAL DIAGNOSIS HTN, Hypothyroidism, Type 2 DM, CKD- stage V, Recurrent UTI Pott s disease (Cervical) INH induced encephalopathy

48 Was discharged on 20/8/15 with advice to F/U after 15 days She is on regular monthly F/U No more HD required

49 CURRENT TREATMENT Tab. Rifampicin600 mg Tab. Ethambutol400 mg Tab. Prednisolone 5 mg ½ +0+0 Tab. Pyridoxine 20 mg Tab. Prazosin 1 mg Tab. Thyroxin 50 µgm Tab. Calcium 500 mg Cap. Cholecalciferol 0.25 µgm Cap. Ferrous sulphate 1+0+1

50 FOLLOW UP (15/02/2016) Anaemia : + Oedema : Absent Vitals : Normal Urine volume : Normal A-V fistula : Functioning GCS : 15/15 Latest S.Creatinine 6.01 mg/dl

51 THANK YOU