MR Wrapup April 12 - 16

Friday: Hypoglycemia and Hypothermia:
54 y/o F with long history of diabetes and renal failure with three previous failed kidney transplants was admitted with temperatures of 87 degrees and a field glucose measurement of 30.  She rapidly improved with passive rewarming and dextrose.  Possible causes included excessive beta blocker dosage as well as excessive insulin, though her low stated dose of 6 units BID make the latter unlikely.  The workup appropriately included evaluation of possible adrenal insufficiency due to her previous history of transplant related corticosteroid use.

Teaching pearls:
Osborn waves and hypothermia:  This particular patients ECG revealed only sinus bradycardia and QT prolongation at 600msec, consistent with hypothermia, but Osborn waves were not manifest on the initial ECG.  This NEJM Case Record has an excellent review of both hypothermia and frostbite management. 

Thursday: Cardiac Device Infection:
A 52 y/o F presented with a constellation of vague complaints to include hands and fingers turning blue associated with some chills.  These symptoms had been present for >2 years off and on.  She also had hematuria of at least 2 years duration without clear cause.  A pulmonary embolism had been documented in the previous year, but no venous thrombus was found in the lower extremities.  She has a history of congenital heart block and had a pacemaker reimplantation approximately 2 years ago prior to the onset of the current symptoms.  On this particular admission blood cultures and an echocardiogram were obtained.  Cultures were positive for coagulase negative staphylococcus in multiple specimens and echocardiography revealed presence of a vegation in the right ventricle.  She improved clinically with intravenous antibiotics and is scheduled for elective surgery to remove the infected pacemaker leads and reimplant a device with epicardial leads.

Teaching Points:
Evaluation of hematuria:  Hematuria is always abnormal in men, and is abnormal in women when not menstruating.  Presence of hematuria during menstrual bleeding should be confirmed with follow up testing after the cycle has ended.  Hematuria is an early warning of many occult, potentially fatal diseases such as carcinoma (bladder or kidney), endocarditis, or glomerulonephritis.  Examination of urine sediment, CT imaging of the urinary tract, and referral for urologic evaluation are all appropriate steps to take.  To quote from a NEJM review of microscopic hematuria: "The single most important test in the evaluation of hematuria is the microscopical analysis of urine, because it often distinguishes glomerular from nonglomerular bleeding."  It appears that this cheap and easily performed test was not performed on several previous episodes of care of this patient. 

Treatment of cardiac device infections:  Huge topic.  Usually involves removal of device in conjunction with a course of antibiotic therapy similar to treatment for endocarditis.  A recent update by former UT ID doc Larry Baddour was published this year in Circulation.  Nice reference if  you ever have to deal with these infections.

Wednesday:  Carbon monoxide poisoning - an elderly female with dementia left her car running in her garage and fell asleep at home.  When she awoke she complained of "smothering".  CO levels were approximately 30% on initial evaluation, and improved promptly with oxygen therapy.  This Clinical Practice article from NEJM is a must read, and covers topics of acute and chronic CO exposure.  Remember that CO induces toxicity both from hypoxic mechanisms but also inflammatory mechanisms, and the latter effect accounts for much of the late toxicity.

MR wrapup for Apr 5 - 9

Diogenes Syndrome Case:

An elderly female admitted with progressive ulcerations over her body.  House was in disarray, she was covered in feces, and had experienced a similar episode one year prior.  She likely has Diogenes Syndrome:  Adult self neglect syndrome, also known as messy house syndrome.  She refused all attempts at placement for skilled nursing care, and denies that any help is needed.  This is a difficult condition to address and there does not appear to be any pharmacologic or behavioral therapy of any great effect.

Sick Sinus Syndrome / Tachy Brady:

A patient with syncope had some episodes of flutter/RVR alternating with sinus pause / sinus bradycardia.  His bradyarrhythmias were only occasionally present on telemetry.  This syndrome is common in older adults with other risk factors for CAD.  Sick sinus syndrome and tachy brady are felt by some to be variants of the same disorder, but in pure sick sinus syndrome the tachycardia is not often seen. 

Other interesting features of this case was the presence of sotalol toxicity.  In this case the patient was a hemodialysis patient and was taking sotalol.  His admit ECG was bizarre with alternating wide and narrow complexes and a prolonged QT > 600msec.  Sotalol toxicity often produces torsades, but this was not seen in this patient and his QT interval normalized with dialysis and discontinuation of sotalol.