Thieves’ Market 2013 J. Scott Neumeister MD { Associate Professor, General Internal Medicine The Nebraska Medical Center.

Thieves’ Market 2013
J. Scott Neumeister MD
Associate Professor, General Internal
The Nebraska Medical Center
Back Pain
A 48 year old male presents with a 3 month history
of low back pain.
His pain started 3 months ago after getting jarred
while on a roller coaster ride. He has been taking
Tramadol and seeing a Chiropractor without any
relief. The pain is worsening and he now has trouble
He has not been able to work at his job as
electrical contractor for this time period.
He has been bruising easily on his arms and
legs without defined trauma. He notes his legs
have been swollen. Furosemide has not
helped reduce the swelling.
He has noticed some difficulty passing his urine
with rare incontinence.
Married. 3 kids. Electrician. No Tobacco.
Rare ETOH. No drugs.
PGM had breast cancer
Tramadol, Furosemide
No allergies
Appendectomy years ago.
98.7 88
16 122/60
Takes 3 people to stand him up
strength, reflexes, sensations intact
proprioception normal
painful with any movement
Back tender along vertebrae diffusely
Bruising on arms and legs, no other skin abnormalities
Edema legs – symmetric, below knees
Prostate normal
No lymphadenopathy
AST/ALT normal
AP 217
Bili 1.3
TSP 4.9
Alb 2.9
B12 normal
TSH normal
141 105 19 108
3.4 27 0.9 9.5
T5, T7 – L5 compression
Some new, some old,
some new on old
UA normal (no protein)
Sed rate 2
SPEP normal
Immunofixation normal
Bone Marrow Bx normal
Vitamin D 60
PTH 30 (normal)
PTHrp negative
Heavy metal screen normal
Dexa – T score -2.8
Z score -2.8
Cortisol 28 (< 18)
Testosterone 32 (180 – 900)
Urinary cortisol 445 (<60)
Salivary gland cortisol elevated X 3
LH, FSH, prolactin, ILGF-1, free T4 normal
ACTH 159 (<46)
MRI Sella – No adenoma noted
“minimal signal intensity heterogeneity”
CT chest – normal
CT abdomen – nodular adrenal gland
Petrosal sinus sampling - ACTH 5437
Pituitary exploration –
Possible adenomatous tissue resected
Path consistent with fibrosis
Follow up urine cortisol normal
Serum cortisol 11
ACTH 61 (<46) - (repeat MRI sella pending)
ACTH Dependent Cushing’s Disease
Petrosal sinus sampling IF adenoma less than 6 mm
? If the side can be localized accurately
Cure rates with surgery - 0 – 80%
Difficult to prove cure, follow annually
Repeat surgery, irradiate, adrenalectomy are future
A 59 year old Caucasian male has a 5 month
history of a non productive cough
He has had progressive SOB. He is having difficulty
walking up a flight of stairs. He still carries 80 pound
bags at work.
He has worked as a forklift operator for the past 4
years. He is exposed to salt dust, feed additive, and
fertilizer dust.
He has lost 80 pounds by following a gluten free/
high protein diet
He took anabolic steroids as a bodybuilder in the
70’s and 80’s
ROS: NO fever
chest pain
hx of heart/lung disease
swollen joints
blood loss
PMH: Solitary Kidney. Rotator cuff surgery. HTN.
FM: Dad with unknown type of cancer.
SOC: Girlfriend. No tobacco, etoh, drugs
All: Bee stings, PCN – anaphylaxis
Symbicort (didn’t help)
Hydralazine 25 mg TID
Metoprolol 25 mg BID
Albuterol MDI
Niacin 1 gm BID
Cialis 10 mg
145/91 73 36.1 16 221 lbs 6’2”
Neurologic normal
Ears normal
Eyes – clear, no injection
Thyroid Normal
Lung: Bilateral Rales
No rashes
No swollen joints
Heart normal
UA Large blood
Mild protein
50 RBC
No casts
138 107 41 107
26 3.3 8.9
lft’s normal
alb 2.6
baseline Cr. 1.7
O2 sat, EKG, ck, troponin, tsh all normal
echo EF 60% LVH, La mild dilated
FEV1 3.65 93%
FVC 4.39 91%
DLCO 99%
CT Bilateral ground glass opacities in a
centrilobular distribution
Bronch – No blood, lavage normal
Viral panel negative
Histo Ag negative
Hemocult neg
B12, folate normal
Iron 6 Ferritin 84 TIBC 259
LDH normal, Haptoglobin normal
DAT IgG +, C3 neg
Sed rate 86
crp 5.9
Epo 28 (4-27)
ANA 1:1280
dsDNA +
anti-histone +
Serine Protease 3 + (assoc with c-anca)
Myeloperoxidase AB + (assoc with p-anca)
C3 84 (90-180)
C4 normal
GBM normal
cryo, hiv, hep B/C negative
Urine protein 500 mg
US – atrophic left kidney, normal right kidney
mild splenomegaly.
Renal bx – Focal necrotizing glomerulonephritis
with mesangial immune deposits
“full house” mesangial deposits
IgG, IgM, C1q, C3, Kappa, Lambda granular
Albumin linear staining
No IgA staining
Hydralazine induced vasculitis/
Drug induced Lupus
Main therapy is cessation of drug however
Hydralazine induced disease typically
requires therapy
Treated with steroids and cyclophosphamide
with near resolution of renal function
10% of patients taking Hydralazine get drug induced
Rare to have renal involvement with drug induced
Rare to have immune complexes in Drug induced
Typically p-anca +, rare to be c-anca
A 77 year old Caucasian male notes several months
of progressive weakness
When he first presented (6 months ago) he was
discovered to have gallstones. His gallbladder
was removed and he felt better for a brief period
following surgery.
He has since lost 35 pounds. He is not eating well.
No specific symptoms
He has had to have his blood pressure meds stopped
or lowered due to low blood pressure
He notes episodes of dizziness upon standing
SOB with exertion
The weakness is worse in his legs
Feels like his feet go “numb”
Muscle/joint pain at baseline with his “arthritis”
NO chest pain
bladder sx
Soc: Trucker/chemical mixer. Married
Lives near Kearney, NE
80 pk yr tob No etoh/drugs
Fm: Dad died of Leukemia
Mom died of ovarian cancer
Sister has thyroid disease
All: None
PMH: Rotator cuff repair, Appy, HTN, GERD
ASA 81 mg
Metoprolol XL 25 mg
Omeprazole 40 mg
Oxycodone/apap 5/325 (2-4 a day)
Biotene Dry mouth rinse
Simethicone as needed
Spironolactone 25 mg
Zolpidem 10 mg
Lisinopril 2.5 mg (has been held)
Albuterol MDI as needed
104/63 73 35.6 20 76.9 kg
Thyroid enlarged
Cranial nerves normal
Rhomberg normal
4/5 strength arms
3/5 strength hips
4/5 strength lower leg
Diminished sensations lower extremities – light touch
Reflexes 1+ patellar, absent ankle
Sats 95%
EKG Normal Trop Normal
N 45 L 36 M 10 Eos 5 Bas 3
CXR atelectasis L base
CT emphysema. small effusions. splenomegaly
ECHO PA pressure 40. trivial valvulopathy. EF 60%
130 93 24 55
4.2 21 1.4 9
alb 2.7 protein 6.0
TSH 0.07 (0.4 – 5)
CK 5
sed rate 44
crp 18
Free T4 0.3 (0.5 to 1.5)
TSI neg
TPO Ab neg
US multiple small nodules favoring benign etiology
SPEP neg
Immunofixation neg
pre-albumin 5.1 (18 -38)
Cortisol 7 (6 – 22)
B12, folate normal
Iron 23 (low)
TIBC 183
Ferritin 442
Vit A 83 (300-1000)
Thiamine 70 (70-180)
Vit D 26 (30 – 200)
Vit E normal
ACTH 11 (0-46)
Cortisol 7.1
30min 13
60min 13
Testosterone <10
FSH 4.9 (1.3-19)
LH 1.7 (1.3-19)
Prolactin 17 (< 13)
ILGF 16 (39-184)
MRI pituitary – normal. Brain small vessel disease.
? if due to hypotension peri/post operative for his
Placed on steroids, testosterone, thyroid,
vitamins A, D, and thiamine
He felt better…..but only for a brief period
He presents with ongoing weakness. Now having
difficulty standing without a 2-3 person assist
Exam significant for 3/5 strength in his major muscle
groups (legs worse than arms)
He is taking his meds. Repeat lab data indicates
a normal T4
CK 5
sed rate 44
crp 18
C5-5 spinal stenosis. Multilevel neural impingement
T spine – mild djd
L4-5 neural abutment. Multilevel djd
Aldolase 11.9 (1.5-8.1)
LP – no oligoclonal bands, cytology neg
EMG (right arm/leg)
Proximal myopathy, peripheral neuropathy
Muscle Bx:
Intravascular Large B-cell
Present with CNS/neuropathy in Caucasians
Present with bone marrow findings in Asians
50% 3 year survival
Joint Pain
A 25 year old female notes red, swollen joints of
her wrists, knees, and ankles
Her joint pain started 3 months ago. It occurred
during the first week of her cycle. It has recurred
each month in a cyclic fashion.
She stopped her birth control pills a few weeks
before the first event.
She has been on and off OCP’s since she was 16 –
started and stopped for no significant medical
She saw a physician who prescribed her
She did not have any problems reaching the summit
of Mount Kilimanjaro (Tanzania), however she
noticed her fingers blanched at the summit.
The finger changes had occurred previously during
cold Boston winters
Her joint pain keeps recurring and is interfering with
her marathon training
She notes also during the last few months she gets
bumps on her arms and fingers that ulcerate
She gets an intermittent sore throat. Approximately
twice a month. She was treated for Scarlet fever
in 2005 but developed a rash after taking
PCN – caused a rash
Prednisone 5 mg for 2 to 3 days for a flare
From Boston. Now lives in Omaha
No tobacco or drugs.
Rare Alcohol
Monogamous relationship
Works in public relations
Brother had scarlet fever also
Mom with Graves’
Mom has intermittent joint swelling – gets better
with prednisone
Notes a red rash on her arms in 2 different places
that has now resolved
Sometimes has palpitations with the onset of her
NO fevers, hair loss, bowel changes, mouth sores,
back pain, urinary complaints, chest pain, or
cycle changes
98/68 16 49 36.5
5’3” 111 lbs
Pharynx normal
thyroid normal
Skin – no rashes
bumps on her right elbow
2nd PIP right scarred lesion (prior bump)
4th DIP left scarred lesion
No joint effusions
No trigger points
137 101 11 83
3.9 26 0.8 9.6
AST 20 Alb 4.6
ALT 17 pro 7.9
AP 59
Bili 0.7
Sed rate 7
crp normal
TSH normal
UA normal
Preg negative
EKG S. Brady
Echo – mild
thick Mitral V.
ANA 1:40
ssB +
Reubella immune
HIV neg
Parvo IgM neg
Parvo IgG positive
Hep B neg
Hep C neg
RPR neg
Rapid strep neg
Throat culture neg
ASO 199 (0-333)
Dnase B Ab 399 (0-120)
What do you think is wrong??
Subcutaneous nodules
Red circular rash(es)
evidence of antecedent strep infection
Rheumatic Fever
Throat cultures are usually negative
ASO titers fall after the first few months
Nodules are the rarest findings
Typically on the elbow (RA are several cm below)
Responds quickly to anti-inflammatories
PCN allergic - Sulfadiazine 1gm a day

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