2000 Clinical Vignette Abstract Winners

First Place

A Paralyzing Mimic of Acute Coronary Syndrome, James V. Beattie, DO, R3, Des Moines Internal Medicine Residency Program, Rahim M. Bassiri, MD, Mentor

Case: 84 yo WF presented with acute onset of chest wall pressure radiating from "armpit to armpit" and intense intrascapular radiating pain. After 2h, she developed bilat LE weakness L>>R and difficulty w/ambulation. These sx fluctuated & seemed to remit w/Tyl#3 prior to presentation to the ER 8h later.

PMH included DM2, HTN, hypothyroidism, CVA X 2, OA. Meds included synthroid, rezulin, glyburide, glucophage, zestril, cardizem. Pt was widowed & lived at an assisted living facility. No etoh/tobacco. Fam hx remarkable only for breast in her mother.

PE: VSS, normal pulmonary & cardiac exam. Neuro exam w/ PERRLA, CN II-XII intact, decr sensation to light touch bilat distal LE, decr coordination LLE, decr DTR throughout, equivical Babinski and unsteady gait. Initial labs w/normal CBC, chem7, coags. CPK was 129 and trop 4.5. ECG was NSR with no acute changes. CXR unremarkable.

Pt admitted for presumed non-Q MI and started on ASA, LMWH, BB. Pain resolved w/ MS04. Pt had subsequent CT head, CT chest, & ECHO which showed no sign of embolic event or aortic dissection. Serial cardiac enzymes were all WNL. Serial ECG showed progressive anterior-lateral T-wave inversion. Pain & neurologic sx fluctuated. Pt taken to cath in light of suspected ongoing ischemia which revealed diffuse CAD with no flow limiting lesions. No intervention was performed and med tx recc. 45 min post angiogram the pt became acutely paraplegic from the nipple line down. MRI revealed T2-3 epidural hematoma w/ subsequent evacuation by neurosurgery. There was no subsequent neurologic recovery.

Discussion: Spontaneous spinal epidural hematoma (SSEH) is a rare clinical event with only 250+ cases reported in the literature. Classic sx include a band-like pain just below the level of the lesion with bilat peripheral neurologic sx. The sx are typically progressive but are frequently reported to have a fluctuating course. SSEH is sometimes assoc with slight trauma (sneeze, cough, etc.) but most arise without precipitating event. Most are 2nd to venous bleeds unless underlying vascular anomaly exist (i.e. AVM, aneurysm). <5% are reported to have spontaneous improvement. SSEH may lead to spinal cord infarction. Deep T-wave inversions are classically found in CNS pathology (stroke, SAH). This phenomenon has not been systemically studied and no association w/spinal cord injury or infarct is found in the literature. However, some animal studies have demonstrated T-wave inversions with spinal cord injury.

Conclusion: In patients who present with apparent acute coronary syndrome and unusual peripheral neurologic sx it is important to keep spinal cord pathology in the differential diagnosis. SSEH is a rare clinical event but it is imperative to recognize it early as it will rarely improve spontaneously and early dx is crucial as neurosurgical evacuation is invariably required. Once dense neurologic deficits have developed, recovery is unlikely even with surgical intervention.

Second Place

Abdominal Pain: Variations on a Theme in A minor, Thomas Lawrie, MD, R3, University of Iowa Internal Medicine Residency Program, Herbert Berger, MD, Mentor

A 16-year old female was admitted with 36 hours of periumbilical pain. She was afebrile and had normal vital signs; physical exam was unremarkable except for mild bilateral lower quadrant tenderness without rebound. Pelvic exam was normal. White blood cell count was 10,000 with no bands, and serum pregnancy test was negative. Pelvic ultrasound was normal. Overnight, she developed nausea and anorexia, and severe lower quadrant tenderness with rebound; repeat WBC was 15,000 with a left shift. Abdominal CT revealed an enlarged appendix with surrounding inflammatory changes. Emergent laparotomy revealed a ruptured appendix; The surgery was uncomplicated.

Following surgery, she had persistent cough and required frequent suctioning of secretions. Although she had a history of asthma, she rarely used an inhaled beta-agonist and was on no other medications. She routinely exercised without dyspnea despite smoking one pack of cigarettes a day. Her past history was remarkable for a chronic cough with sputum production of approximately a tablespoon per day, and she had numerous sinus infections. Chest exam was remarkable for diffuse coarse crackles in all lung fields. The heart had normal sounds and no murmurs. The abdomen was mildly obese and had good bowel sounds. There was no organomegaly; her surgical wound was well-healed. Serial chest radiographs revealed fleeting atelectatic areas in both lower lungs. A pulmonary consult was obtained, and a diagnostic procedure was performed.

Third Place

A Question of Risk, Christine M. Lindgren, DO, PhD, R3, Des Moines Internal Medicine Residency Program, Hala Shamsuddin, MD, Mentor

Case: G.S. was a 66 yo female without significant past medical history who was admitted to IMMC on transfer from a community hospital after 8 d. hospitalization for dyspnea, non-productive cough, fever. She had experienced a 30# weight loss, increasing malaise/fatigue, intermittent fevers since hip fracture 3 mo before. At local hospital CXR was remarkable for bilateral interstitial infiltrates, a sputum culture was negative and labs were remarkable only for leukopenia. She was hypoxic, requiring 6L 02 to maintain adequate oxygen saturation.

Exam after transfer showed a pale, weak, tachypneic female with large A-a gradient on 100% NRBM, lungs with bibasilar crackles. WBC with absolute lymphopenia. Bronchoscopy revealed purulent secretions with rare yeast negative DFA, Pneumodystis carinii. Etiology of immunosuppression was found to be HIV infection. G.S. was treated for PAC but in spite of aggressive ventilatory support continued to deteriorate and after finding of Pseudomonas and Cryptococcal pneumonia, HSV-1 oral infections, Candida mucocuaneous lesions, she died of multi-organ system failure.

Discussion: G.S.'s medical history was negative with exception of severe spider bite evolving to gangrenous infection (1990). Surgical history was remarkable for hysterectomy in 1980 and femoral neck fracture repair in 1998; each surgery required transfusion of 2 units of packed red cells. Her social history was typical of an Iowa farmwife, i.e. non-smoking, non-drinking, no unprotected sexual encounters. Her occupation from 1980-1995 was as a part-time nurse's aide at a small Des Moines hospital. Investigation through the Blood Bank of Central Iowa revealed the donors of blood transfusion to be negative for HIV Ab or Ag. She had no documented occupational exposure to HIV+ contaminated fluids. Her husband was HIV-. She had never used IV drugs. Interestingly, evaluation of CBC at time of hip fracture repair 3mo prior to her presentation with AIDS revealed pancytopenia with absolute lymphocyte count of 0.5 th/mm.

G.S. had no strong risk factors for HIV infection. Her occupation and transfusion history put her at very low risk.

Patients diagnosed with HIV infection/AIDS are classified according to risk factor. These categories include MSM (men who have sex with men), IVDU (IV drug users). MSM-IVDU, heterosexual sex, transfusion, hemophiliac/coagulation disorder. The percentage of patients who fall into "other/no risk identified" is small though increases yearly. This case highlights the usefulness as well as the danger of over-reliance on risk factors when faced with an immunosuppressed patient.

Third Place

Headache and an Incomplete Horner's Syndrome in a Migraineur, Charles Longo, MD, R3, Des Moines Internal Medicine Residency Program, Calvin Hansen, MD, Mentor

Case: A 50 year old male with a long history of migraine headache presented with 2 weeks of a constant right temporal/periorbital aching pain that was more severe than his usual headache pattern. The pain was not relieved by his standard migraine medications. He was noted to have a right Horner's syndrome. Work-up prior to admission included a negative head CT, MRI and MRA.

Physical Examination: Pertinent exam findings included right eye ptosis and miosis. The remainder of the neurologic exam was normal. Heart was regular, lungs were clear, abdomen benign, and extremities were without edema.

Lab: CBC and chemistry panels were normal. Carotid angiogram revealed right internal carotid artery dissection beginning at C3 and extending into the intrapetrous portion of the artery.

Hospital Course: The patient's pain improved with parenteral narcotics, IV heparin, and then Coumadin.

Discussion: Carotid artery dissection is an unusual phenomenon in middle-aged patients. The etiology is unknown but thought to include inherent defects in the arterial wall that predispose to dissection in association with trivial trauma. Presenting symptoms may include headache, and an incomplete Horner's syndrome (oculosympathetic paresis). These are due to inflammation of the artery as well as disruption of the plexus that surrounds it. Carotid angiogram is the gold standard for diagnosis. Anticoagulation with Coumadin or an antiplatelet agent is the standard of care.

Conclusion: The presence of oculosympathetic paresis with head and/or neck pain in a relatively young patient should increase suspicion for diagnosis of carotid artery dissection.

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Richard F. LeBlond, MD, MACP,
Governor, Iowa Chapter

Fran Blanc
Ph: 319-467-5595
Fax: 319-384-8214
E-mail: francoise-
blanc@uiowa.edu