Andy Romeo co-hosted my last morning report ever! We talked about a middle aged man with myelitis, meningitis, and radiculopathy that remains a diagnostic mystery. We developed an approach to myelitis and myelopathy.
Transverse myelitis definition
- Bilateral (doesn’t have to be symmetric) motor deficit + sensory deficit + bowel/bladder sx that localizes to the cord
- defined sensory level
- progression->nadir of symptoms in 4 hours->21 days (so not hyper acute and not chronic)
- If a patient only has sensory or motor deficits rather than all three, they have partial myelitis.
Extrinsic Compression (usually causes myelopathy)
- fracture, degenerative disease, disc
- B12 deficiency (AKA subacute combined degeneration)
- anterior spinal artery infarct
- demyelinating disease
- acute disseminated encephalomyelitis
- infectious or post-infectious
- WNV, HSV, HIV, HTLV-1, Zika
- lyme, mycoplasma, syphillis
- pyogenic bacteria rarely cause intrinsic spine dysfunction (usually compressive)
- other rheumatologic conditions
- Mixed connective tissue disease
- leptomeningeal lymphoma or solid tumor
- idiopathic – 30% of transverse myelitis is ultimately thought to be idiopathic
- Imaging is key! Start with a sagittal survey of the whole spine, then zoom in on the area of suspected deficit + anything that looks abnormal on the sagittal survey.
- Most need an LP and a big serologic workup. Here’s starting recommendations from NEJM
- this patient was treated empirically for cryptococcal meningitis but there was still concern for cancer – either leptomeningeal carcinomatosis or lymphoma. It turns out that the flucytosine in his crypto regimen can occasionally, partially treat a malignancy, which could explain the improvement in his symptoms.
- A very high CSF protein level will cause xanthochromia that is unrelated to lysis of RBCs
Frohman EM. Wingerchuk DM. Transverse myelitis. NEJM 363;6. 564-572
Filed under: Morning Report
Thanks to Max W for presenting a case of a peritonsilar abscess in a patient with a hx of organ transplant who was found to have necrotizing HSV tonsillitis requiring incubation for subglottic/epiglottic edema
Peri-Tonsillar abscess in immunocompetent patients
(bread and butter)
This diagnosis can be made clinically based on suggestive sx – hot potato voice, pain with swallowing, 2/3 have truisms – and an exam with uvular deviation and a swollen tonsil.
- Annual incidence is 30/100,000 people with a peak onset during adolescence
- By contrast, appendicitis has an incidence of 233/100,000 people. Common enough that high volume emergency rooms see it on the regular but not as common as pneumonia.
- Risk factors include smoking, recurrent tonsillitis, and oropharyngeal cancer or radiation.
- Often progresses from exudative tonsillitis->tonsillar cellulitis->abscess
- Usually bacterial and polymicrobial with an over-representation of GAS, s milleri and anaerobes esp fusobacterium.
- Always consider the ddx of other deep neck space infections from mouth to mediastinum
- ludwig’s angina
- septic IJ thrombophlebitis (Lemierre’s disease)
- retropharyngeal abscess
- tracheal inflammation or infection
- Evaluate for impending airway compromise
- Difficulty managing secretions, voice changes, dyspnea. Stridor is a late sign
- Consider direct laryngoscopy if any concern.
- Aspirate that pus!
- We rarely admit paratonsilar abscesses. Usually ENT/the ED aspirates them, they get better and go home.
- Ultrasound can increase the yield of aspiration.
- If no pus is aspirated or symptoms do not improve, they should be admitted
- amox/clav and clinda are great PO options.
- Consider MRSA like you would in any other cellulitis. If so, they may need admission/IV vanc
- Small studies show evidence for a single dose of 10mg of dexamethasone to speed recovery.
PTA in severely immunocompromised patients
(ancient grains with caviar)
Main difference is in causative agents. Also consider…
- pseudomonas, MRSA, HSV (case-reportably rare, that’s what this patient had), candida (usually more slowly progressive.)
- initial abx management is often broad – don’t be afraid to call ID! This patient was started on vanc/piptazo/acyclovir.
- If pus cannot be aspirated, consider biopsy to guide dx therapy
- HSV tonsillitis improves with acyclovir.
References (and source of images)
Galioto NJ. Peritonsillar Abscess Am Fam Physician. 2017 Apr 15;95(8):501-506.
Filed under: Morning Report
Report this morning at ZSFG was inspiring. The case was super interesting – a woman who presented with hyponatremia which was found to be 2/2 LONG undiagnosed (like 30 year) hypo pit from postpartum pituitary hemorrhage.
Chief confession time
I think hyponatremia is really hard. In report today, a room full of super wise residents, medical students and Lisa Murphy helped develop a clear, comprehensible hyponatremia algorithm. Here is my deep, philosophical conclusion, that will also help you use this algorithm
- Most diagnoses are simple with history, exam, and 3 lab tests. A small portion are wicked hard to diagnose.
- Simple: this patient has been vomiting for a week is on a thiazide. The diagnosis is diuretics + hypovolemia. The patient has pneumonia and has been drinking plenty of water. The diagnosis is SIADH. In these situations, you can use the algorithm below to make confirm your diagnosis and ensure nothing else is going on.
- Wicked hard: The numbers don’t fall into any of the above buckets, are in a grey zone, the patient is obtunded or you thought you knew the answer but the patient isn’t getting better.
- GI bleeds are this way too! Most of them are clear from history and basic physical exam. Then there’s the occasional small bowel angioectasia that has you banging your head against the wall
- Volume status
- While basing your hyponatremia algorithm on volume status is laudable, in reality, assessing volume status is hard! So this trips people up a lot.
- See below for a volume status-free algorithm.
Simplified hyponatremia algorithm
- adapted from Miliones HJ, Liamis GL, Elisa MS. The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ 2002; 166 (8): 1056-62. Chart made with Lucidchart.
- A caveat: none of these branch points are true 100% of the time. The lower down you get on the algorithm, the less accurate it is, like the Brugada criteria. Uric acid levels are particularly iffy – they are most sensitive for SIADH when they are <4
- The uric acid pearl, is one of VA LT’s favorites. ADH promotes Urea/uric acid excretion along with water retention.
Tips for wicked hard hyponatremia
- The algorithm in the Miliones article above which has more detail, explains what to do with intermediate values, and gives some specific suggestions for testing
- Make a hypothesis, try a treatment, and recheck the big 4 – serum sodium, urine sodium, serum osms, urine osms.
- Renal and endocrine can help you if you’re lost!
Managing hyponatremia is super important and pearls for another time. Search the archives for tons and tons of other hyponatremia pearls.
Filed under: Morning Report