Friday, 22 June 2007

Devil's Grip

A young adult male was admitted to another institution with severe upper chest pain that awoke him from sleep.

He had been previously well and had no serious underlying problems.

The pain was located in his upper chest and was severe (9/10) and made worse by lying flat. The pain was squeezing in nature, radiated to his back and was non-pleuritic. There was no associated breathlessness, cough, sputum or haemoptysis. The pain did not radiate to his neck, jaw or arms. He felt nauseated and sweaty but had not vomited.

He also complained of right upper quadrant abdominal pain. He had no other abdominal symptoms including the absence of diarrhoea, constipation, jaundice or malena.

On direct questioning, he denied doing any recent heavy lifting. He complained of no neck pain although he did mentioned that he had new onset 'katakori'. He did not have a stressful occupation.

Previous history included hyperlipidaemia, appendicetomy.

He was taking no regular medications.

He was a previous smoker having given up last year.

When he was initially examined there was a positive finding of fever which was low grade. The chest examination was unrevealing. Abdominal examination showed some right upper quadrant tenderness but no organomegally.

All bloods were normal except for a raised neutrophil count, low lymphocytes and rising CRP.

Initial differential diagnoses included;

  • Acute MI
  • Unstable angina
  • Variant angina
  • PE
  • Aortic dissection
  • Spontaneous pneumothoraces
  • Spontaneous rupture of oesophagus with surgical emphysema
  • Oesophageal spasm
  • Gastritis
  • Pericarditis

The serial ECGs revealed no pathological changes.

Chest radiograph showed no evidence of surgical emphysema, pneumothorax or enlargement of the superior mediastinum.

CT chest was performed and dissection was ruled out.

Echocardiogram of the heart revealed some mild left ventricle asynergy and abdominal scanning was normal.

In view of the abnormal echocardiogram result, the patient underwent coronary angiography which was normal.

Hence, despite the serious pains, no major abnormality could be found.

On further review on attending the same institution for review, the pain had mostly resolved, but he was left with some persistent abdominal discomfort and blood tests were still abnormal.

Examination was completely unremarkable.

The only major abnormality was the evidence of an inflammatory / infective episode. The mild LV asynergy made me consider a coxsackie infection. However, the CK and ECG were normal.

The diagnosis to be somewhat unusual and referred to as Bornholm Disease, but also known as Pleurodynia or Devil's Grip.

This is a viral infection caused by Coxsackie B virus (1-5 isotypes) affecting the diaphragmatic and intercostal muscles. It causes painful spasm and fever, and it can simulate the painful and potentially serious pathologies consider above. The condition occurs in summer months (hence, at this time) and adults are affected to a greater degree than children.

Having reviewed several texts, the general description is poorly reported with there being no definite bedside diagnostic criteria although a rising titre of anti-coxsackie antibody should be normally be checked . However, this is a diagnosis of inclusion when all other serious diagnoses have been ruled out.

Pleurodynia generally resolves with 6 days and treatment is with analgesics.

Wednesday, 20 June 2007

Don't Ignore Your Patient's Symptoms

This patient was admitted to a hospital and details have been anonymised.

The patient is an elderly male with a long history of rheumatoid arthritis who been admitted with non-specific symptoms of
  • fever
  • malaise
  • back pain
The patient was vague and confused so was not able to answer questions clearly, but it appeared that there were no localising symptoms to the chest, CNS, abdomen, genitourinary tract, joints or skin.

There was no other significant history.

The patient had been taking long term steroid (prednisolone 5mg / day) and NSAIDs. The patient had not been on any DMARDs.

Physical examination performed by another doctor was described as generally unrevealing except for the signs of cold shock, and features of chronic steroid administration which included a Moon Face, a Buffalo hump, Centripetal obesity and the obvious signs of advanced RA of the hands.

Blood results suggested renal failure, sepsis and DIC, and he underwent renal ultrasound scanning which revealed an infected hydronephrotic right kidney.

As the coagulation was deranged, the patient who would have normally had nephrostomy tube insertion instead had a double J stent inserted from renal pelvis to bladder in order to allow drainage of the infected kidney.

Microbiological results revealed the infecting organism to be Proteus mirabilis.

He was also treated with broad spectrum antibiotics and received iv steroid replacement in view of the real potential for an Addisonian crisis in view of his prolonged period having received oral steroids for the rheumatoid arthritis over the years.

The patient's inflammatory markers began to settle and the renal failure improved. However, the patient developed an ensuing haemolytic anaemia with raised bilirubin, raised reticulocytes, but normal Coombe's test. Other testing for GI evidence of bleeding was negative.

It was clear that there was some process still driving the haemolysis despite the improving infection from the Genitourinary tract.

The back pain had essentially been overlooked because the patient had had a long history of back pains and of course, an infected kidney can also cause back pain. However, other pathology such as infection which could be causing this back pain had not be investigated and excluded and moreover, the infection was supposed to be improving and therfore one would have expected the back pain to also get better!

When the patient was questioned, he said that the pain in his back had changed and had become worse than usual. It was so painful, that the usual pain medications were not proving to be effective.

It was therefore decided to perform a CT scan of the lower abdomen and back which astoundingly revealed a psoas abscess!!!!!

What this case shows is not to ignore or overlook the most trivial of symptoms as they may lead to a diagnosis that had clearly not been considered on admission to hospital. Back pain is a very common symptom especially in patients with arthritis. However, never forget that RA patient by dint of their autoimmune state are relatively immunodeficient and in addition, the patient had been taking steroids further impacting on immune suppression. That puts them at greater risk for infections.

The change in the nature of the back pain and the fact that it was enough for the patient to complain about it was enough for it to be investigated. Just because a patient has a chronic condition does not mean to say that it should not be investigated during an admission to hospital as the condition may have deteriorated or become complicated, as in this case by infection.

Let's suppose the patient had COPD. Just because the patient has a chronic pulmonary condition does not mean to say if breathlessness gets worse then it should not be investigated, does it?! Without such investigation, a pneumothorax, infection, PE, tumour etc would be missed. Hence, the same is for other areas of the body including the back or any other chronically affected area / organ system.

Basically, this boils down to Listening to Your Patient and taking them seriously. Sometimes in these chronically ill patients, it is better to over investigate and come up with normal results than to under investigate and miss the diagnosis.

Remember, that patients who are elderly or immunosuppressed for whatever reason will not always show a raised white count, fever, tachycardia etc in response to infection. In such patients, have a low threshold for treating.

It proves that in this case, despite an abscess being present, the inflammatory markers were improving!! The main feature for making certain that the patient was scanned, was the fact that there had to be a severe pathological process driving the haemolytic anaemia.

The haemloysis was probably due to localised-subacute DIC and the anaemia resolved once the abscess was drained.

This patient underwent retroperitoneal drainage of the abscess and full microbiological results revealed Proteus mirabilis as in the urine.

Things to Remember:

  • Listen to your patient
  • Examine all the areas complained about by the patient
  • Investigate affected areas
  • Treat !