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ANSWER 82

This woman has the typical clinical symptoms of polymyalgia rheumatica/giant cell arteritis. Most patients are over 65 years. The onset of symptoms is often sudden. Patients may present primarily with polymyalgia-type symptoms (proximal muscle pain and stiffness most marked in the mornings) or temporal arteritis symptoms (severe headaches with tenderness over the arteries involved). Patients may have systemic symptoms such as general malaise, weight loss and night sweats. Characteristically, the ESR is very elevated (at least 40 mm/h) and there is a mild anaemia and leucocytosis. The liver enzymes are often slightly raised. In polymyalgia, the main symptoms are muscle stiffness and pain which may simulate muscle weakness. The creatine kinase is normal, unlike in polymyositis.

The diagnosis of polymyalgia rheumatica is essentially a clinical diagnosis. A very elevated ESR is useful. Around 25 per cent of patients with giant cell arteritis have polymyalgia. When there are headaches and giant cell arteritis is suspected, a temporal artery biopsy should be performed. However, the histology may be normal because the vessel involvement with inflammation is patchy. Nevertheless, a positive result provides reassurance about the diagnosis and the need for long-term steroids.

This patient has clear evidence of giant cell arteritis (also known as temporal arteritis although other vessels are involved), and is at risk of irreversible visual loss either due to ischaemic damage to the ciliary arteries causing optic neuritis, or central retinal artery occlusion. The patient should immediately be started on high-dose prednisolone (before the biopsy result is available). The steroid dose should be slowly tapered according to clinical features and ESR, but is likely to need to be continued for around 2 years. Bone protection measures should be part of the management.

!Differential diagnoses of proximal muscle weakness and stiffness

•Polymyositis

•Systemic vasculitis

•Systemic lupus erythematosus

•Parkinsonism

•Hypothyroidism/hyperthyroidism

•Osteomalacia

KEY POINTS

•Polymyalgia rheumatica and giant cell arteritis often co-exist.

•Patients with these conditions have markedly elevated ESR levels.

•There is a risk of blindness in giant cell arteritis, and steroids should be started immediately.

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CASE 83: WEAKNESS

History

A 76-year-old woman presents to the emergency department complaining of an episode of weakness in her right arm and leg. She was sitting down with her husband when the weakness came on and her husband noticed that she slurred her speech. All of the symptoms resolved within 10 min. Her husband has noticed two to three episodes of slurred speech lasting a few minutes over the last 6 months but had thought nothing of it. Two months earlier she had a sensation of darkness coming down over her left eye and lasting for a few minutes. She has had type 2 diabetes mellitus for 6 years, controlled on diet. She is hypertensive and suffered a myocardial infarction 3 years previously. She smokes about 10 cigarettes per day and drinks alcohol rarely. Her only medication is enalapril for her blood pressure.

Examination

She looks frail. Her pulse rate is 88/min irregular and blood pressure 172/94 mmHg. The apex beat is displaced to the sixth intercostal space, mid-axillary line. Her heart sounds are normal and a grade 3/6 pansystolic murmur is audible. A soft bruit is audible on auscultation over the left carotid artery. Her dorsalis pedis pulses are not palpable bilaterally and her posterior tibial is weak on the left and absent on the right. Examination of her chest and abdomen is normal. Neurological examination demonstrates normal tone, power and reflexes. There is no sensory loss. Funduscopy is normal.

INVESTIGATIONS

Questions

•What is the diagnosis?

•How would you manage this patient?

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ANSWER 83

This woman gives a history of transient neurological symptoms with no residual signs. She is at increased risk of cerebrovascular disease because of her smoking, hypertension and diabetes. She is describing recurrent transient ischaemic attacks (TIAs) which by definition resolve completely in less than 24 h, and, in practice, often much quicker. Two months before her admission she had an episode of amaurosis fugax (transient uniocular blindness) which is often described as like a shutter coming down over the visual field of one eye. The TIAs are affecting the left cerebral hemisphere in the area of brain supplied by the left carotid artery causing right-sided weakness and dysarthria. TIAs may be caused by thromboembolism from ulcerated plaques in the carotid arteries or aortic arch, from cardiac sources such as a dilated left atrium, and more rarely due to haematological causes such as polycythaemia rubra vera, sickle cell disease or hyperviscosity due to myeloma. The symptoms may be the same each time or vary. Her ECG shows atrial fibrillation and she has the signs of mitral regurgitation with a pansystolic murmur and displaced apex beat. There are three obvious potential sources for emboli:

•a left carotid artery stenosis (in a correct location to account for the distribution of these TIAs and more likely in the presence of a carotid bruit)

•the left atrium in atrial fibrillation with clinically evident mitral regurgitation

•a previous myocardial infarction with mural thrombosis.

!Major causes of transient neurological syndromes

•Migraine: the aura of migraine is a spreading and slowly intensifying phenomenon and the symptoms are usually positive, e.g. scotomata. The aura is usually followed by a severe headache. However, migraines can be associated with focal neurological deficits, e.g hemiplegia.

•Focal epilepsy: this also normally causes positive symptoms such as twitching and sensory symptoms which may march up one limb and from one limb to another on the same side.

•Syncope: unlike most TIAs there is loss of consciousness but there are usually no focal signs. Dizziness often precedes the attack.

•Space-occupying lesion: a cerebral tumour or abscess can produce fluctuating symptoms and signs. The symptoms are usually more gradual in onset and are often associated with headaches or personality changes.

•Miscellaneous: hysteria, cervical spondylosis, hypoglycaemia and cataplexy.

This patient should be investigated with a computed tomography (CT) of the head to exclude a structural space-occupying lesion, echocardiography to assess left-atrial size, the mitral valve (to exclude infective valvular vegetations) and to rule out thrombus in the left ventricle related to the previous infarct, and a Doppler ultrasound of the carotid arteries. If a critical carotid stenosis (#70 per cent) is present, carotid endarterectomy should be considered. The patient should be anticoagulated with warfarin because of her atrial fibrillation and carotid stenosis. Her blood pressure and diabetes should be carefully controlled and her lipids measured and treated if appropriate.

KEY POINTS

•Most transient ischaemic attacks persist for only a few minutes.

•Approximately 40 per cent of patients with cerebral infarction have a prior history of transient ischaemic attacks.

•Multiple risk factors need to be taken in to account in the investigation and management of vascular disease.

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CASE 84: VOMITING

History

A 32-year-old man presents to the emergency department at 2 am rather inebriated. He had been to an end of examinations party that evening, followed by a Chinese meal. He began to feel unwell around 11.45 pm and vomited twice, brought up his meal and several pints of lager and initially felt better. Over the next hour or so he retched violently on several occasions and around 1 am vomited up bright red blood. He says that he noticed just a small amount of blood on the first occasion but considerably more the second time.

There is no relevant previous medical history or family history. He smokes 10 cigarettes a day, takes occasional marijuana and drinks 2–3 units of alcohol a week.

Examination

He seems a little drunk. There is some dried blood around his mouth. The pulse is 102/min and the blood pressure 134/80 mmHg lying, with no change on standing and no other abnormalities in the cardiovascular or respiratory system. In the abdomen there is a little tenderness in the epigastrium.

INVESTIGATIONS

Questions

•What is the likely diagnosis?

•What is the appropriate management?

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ANSWER 84

The most likely diagnosis is a tear of the mucosa in the lower oesophagus or upper stomach causing haematemesis (a Mallory–Weiss lesion). This is produced from the mechanical trauma of violent vomiting or retching. In this case, it may have been triggered by an unaccustomed large alcohol intake.

The estimation of blood loss is often difficult from the patient’s story. Haematemesis is a frightening symptom and the amount may be overestimated. The haemoglobin level here is normal and it is unlikely to be helpful in an acute bleed. If it were low at this stage it would be more likely to imply chronic blood loss. The first signs of significant blood loss would be likely to be tachycardia and a postural drop in blood pressure. His pulse is fast but this may well be related to anxiety.

Other possible causes of haematemesis are gastritis or peptic ulcer. The story of retching and vomiting of gastric contents with no blood on several occasions before the haematemesis is characteristic of Mallory–Weiss syndrome. This is usually a benign condition which does not need intervention. Definitive diagnosis requires upper gastrointestinal endoscopy but is not always necessary in a typical case. Occasionally the blood loss is more substantial or the split in the wall may be deeper than just the mucosa, leading to perforation.

Management in this case was with careful observation, intravenous fluid to replace lost volume from vomiting. Blood was taken for blood grouping in case of more substantial haemorrhage but transfusion was not necessary. He was treated with an anti-emetic and an H2-blocker. The vomiting settled and there was no more bleeding. He decided to indulge less at future parties.

KEY POINTS

•A history of violent retching or vomiting without blood before haematemesis suggests an upper gastrointestinal mucosal tear.

•It is difficult to be sure of the degree of blood loss in haematemesis because the patient will find it difficult to quantitate the volume of blood, and the amount of blood still in the gastrointestinal tract is unknown.

•In some surveys alcohol is linked directly to around one-quarter of acute medical admissions.

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CASE 85: TIREDNESS AND IRRITABILITY

History

A 33-year-old housewife has noticed that she is becoming tired and having difficulty coping with her two children, aged 6 and 4 years. She goes to see her general practitioner (GP) because she feels she may be suffering from anxiety and depression. She says that she has felt more irritable and anxious than usual. Her sleep is normal. Her appetite has been normal but she has lost some weight. Her change in personality has been noticed by her husband and friends. She feels constantly restless and has difficulty concentrating on a subject for more than a few moments. Her increased anxiety has developed over the past 3 months. She has also noticed an increased frequency of bowel movements. Her periods have become lighter and shorter. She feels extremely tired, and thinks that she has been prone to sweat more than usual. She has had no significant illnesses previously. She is a non-smoker and drinks 10 units of alcohol per week.

Examination

She appears agitated and her hands are sweaty and tremulous. Her pulse is 104 and regular, her blood pressure 130/70 mmHg. Her proximal muscles seem a little weak. There are no abnormalities in the cardiovascular, respiratory, abdominal or nervous systems. Investigations are organized by her GP.

INVESTIGATIONS

Questions

•What is the most likely diagnosis?

•How would you manage this patient?

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ANSWER 85

Although anxiety might produce some of these symptoms and signs, they fit much better with a diagnosis of hyperthyroidism. The neck should be examined carefully and in this case there was a smooth goitre with no bruit over it. Blood tests showed a very low thyroxinestimulating hormone (TSH) level and a high free thyroxine (T4), confirming the diagnosis of hyperthyroidism due to a diffuse toxic goitre (Graves’ disease). Hyperthyroidism may mimic an anxiety neurosis with marked restlessness, irritability and distraction. The most helpful discriminatory symptoms are weight loss despite a normal appetite and preference for cold weather. The most helpful signs are goitre, especially with a bruit audible over it, resting sinus tachycardia or atrial fibrillation, tremor and eye signs. Eye signs which may be present include lid retraction (sclera visible below the upper lid), lid lag, proptosis, oedema of the eyelids, congestion of the conjunctiva and ophthalmoplegia. Atypical presentations of thyrotoxicosis include atrial fibrillation in younger patients, unexplained weight loss, proximal myopathy or a toxic confusional state. The weakness here is suggestive of a proximal myopathy. The very low TSH level indicates a primary thyroid disease rather than overproduction of TSH by the anterior pituitary.

!Common causes of hyperthyroidism

•Diffuse toxic goitre (Graves’ disease)

•Toxic nodular goitre

multinodular goitre (Plummer’s disease) solitary toxic adenoma

• Over-replacement with thyroxine

Blood should be sent for thyroid-stimulating immunoglobulin which will be detected in patients with Graves’ disease. Medical treatment for thyrotoxicosis involves the use of the antithyroid drugs carbimazole or propylthiouracil. These are given for 12–18 months but there is a 50 per cent chance of disease recurrence on stopping the drugs. If this happens radioiodine or surgery is indicated. Beta-blockers can be used to rapidly improve the symptoms of sympathetic overactivity (tachycardia, tremor) while waiting for the antithyroid drugs to act. Radio-iodine is effective but there is a high incidence of late hypothyroidism. Surgery is indicated if medical treatment fails, or if the gland is large and compressing surrounding structures. In severe exophthalmos there is a risk of corneal damage and ophthalmological advice should be sought. High-dose steroids, lateral tarsorrhaphy or orbital decompression may be needed.

KEY POINTS

•Thyrotoxicosis may be difficult to differentiate from an anxiety state.

•The commonest causes of hyperthyroidism are Graves’ disease or a toxic nodular goitre.

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