jmj11 Posted June 28, 2011 Share Posted June 28, 2011 Okay, I haven’t presented a case in a while. This is true case that I’m involved with right now and there is not a definitive dx yet . . . but stay tuned. A 71 year old woman over the course of a day or so developed right upper back, shoulder and neck pain (May 1st). It started as a 6/10. She eventually sought help from a masseuse. For the following hour she felt better but then the pain quickly rose to a 11/10 (the worse pain of her life). The pain continued across her trapezious area, but still more on the right, the neck and moving into her occiput. She goes to her island clinic (btw she lives on a remote Puget Sound island) where she is given a shot of Demerol and some take home diazepam for “muscle strain.” Those meds did not help at all and she sat up the entire night with 10/10 pain. A few days later, still in severe pain, appeared to the clinic again. She was given morphine via IV, more diazepam. During the visit her temp was recorded at 100 F and her neck was stiff. With the fear of meningitis, she was air-lifted to the mainland medical center. In the medical center her temp was back to normal so a spinal tap was deferred. Her pain was still 10/10. She was given Dilaudid and phenergan by IV with 5% improvement and she had a CT head, which was normal. Labs in the ER had WBCs at about 12,000 (don’t ask for the diff because I don’t have it in front of me) and her sed rate was 29. She was scheduled on the mainland for a cervical MRI the next morning and she stayed in a hotel. The next morning she had her cervical MRI which showed the following: IMPRESSION: Multilevel cervical spine degenerative disc disease as detailed above by spinal level, with the most severe canal narrowing seen from C4-C6, which is predominately left-sided at C5-C6. Grade 1 anterolisthesis of C3 on C4. The MRI was reviewed by a neurosurgeon the next week in prep for an appointment. He said that this was not operable, didn't want to see her, probably not related to her dominate right sided pain (which he guessed was muscular) and a referral should be made to PT. She visited her PCP again still in 10/10 pain. In desperation (as no pain med helped) he put her on a new muscle relaxer AND prednisone 60 MG a day for 5 days then tapered off. The steroids gave her a profound benefit (pain free by the end of the first day) for the first time in the two weeks since it had started. However, as she was coming off the prednisone, not only did the back, shoulder and neck pain return but she developed a severe holocephalic headache with severe (10/10) bilateral facial ( V1-2) stabbing pain, sore mouth and throat. At that point, the patient was referred to my headache clinic for possible Trigeminal Neuralgia. When the PCP called me I asked him to do a Sed Rate and CRP. . . he did a sed rate. He also gave her more morphine, and 120 MG of Medrol. She caught the early morning ferry over to my island and I worked her in at 7 AM. When I saw her, she was once again completely symptom free and elated. Her sed rate came in a 44 and the CRP was not done. I have a few more points and developments but any thoughts or discussion at this point? Link to comment Share on other sites More sharing options...
rcdavis Posted June 28, 2011 Share Posted June 28, 2011 Were the back muscles tender to palpation or movement? Were there any proximal muscle / motor weakness? Any pelvic girls pain accompany the should girdle pain? Does her island/ area of the country have any rickettseial -tick borne disease Prediliction? Was there any rash? Any visual problems? And was there a total CPk level drawn? If elevated, was there an aldoase level done? And finally , was the cxr normal? davis Link to comment Share on other sites More sharing options...
xxbowiexx Posted June 28, 2011 Share Posted June 28, 2011 my guess is that it could be some form of vasculitis. Horton's disease maybe, may couple with polymyalgia rheumatica. Curious to see what's the dx would be. Link to comment Share on other sites More sharing options...
jmj11 Posted June 28, 2011 Author Share Posted June 28, 2011 I highly suspect PMR with a possible TA. I got a temporal art bx today, results pending, and I have an appointment set up for her with rheumatology on Thursday. I have her on a maintenance dose of Medrol oral 48 MG first 4 days and then 32 MG. There are some things that sound like PMR (profoundly steroid responsive) but some things that are a little odd. Also, the on again off again treatment with steroids over the past 7 weeks seems to have confused the picture even more. Link to comment Share on other sites More sharing options...
jmj11 Posted June 28, 2011 Author Share Posted June 28, 2011 Were the back muscles tender to palpation or movement? Were there any proximal muscle / motor weakness? Any pelvic girls pain accompany the should girdle pain? Does her island/ area of the country have any rickettseial -tick borne disease Prediliction? Was there any rash? Any visual problems? And was there a total CPk level drawn? If elevated, was there an aldoase level done? And finally , was the cxr normal? davis Funny, I replied to your questions but it never posted for some reason. When I saw her she was not tender at all and she had no weakness (day after her medrol). During her flare up she had no focus weakness but profound generalized fatigue and malaise. She had no visual changes. Link to comment Share on other sites More sharing options...
d2305 Posted June 28, 2011 Share Posted June 28, 2011 Can't MS present with weird neurological Sx as above? Brain MRI? Link to comment Share on other sites More sharing options...
rcdavis Posted June 28, 2011 Share Posted June 28, 2011 Hmmm.. Was mulling this case over in my mind last night. The nightmare is that she doesn't have pmr or an unusual form of myositis.. But that she is having pain of aortic dissection and neck artery dissection. ( cannot explain why this dx would have pain relief with steroids though) A negative ta bx does not completely r/o arteritis.. Which as you know can be segmental. I would like to also see a muscle biopsy, though again the steroids will have affected the result. davis Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 28, 2011 Moderator Share Posted June 28, 2011 initially I was concerned about small SAH(which I have seen start as neck pain and progress to h/a) as she never got that LP but steroid response makes PMR go to the top of my list. Link to comment Share on other sites More sharing options...
jmj11 Posted June 28, 2011 Author Share Posted June 28, 2011 Can't MS present with weird neurological Sx as above? Brain MRI? Sometimes it will present with a trigeminal neuralgia type syndrome, but not with this other pain as far as I know. Link to comment Share on other sites More sharing options...
jmj11 Posted June 28, 2011 Author Share Posted June 28, 2011 Hmmm.. Was mulling this case over in my mind last night. The nightmare is that she doesn't have pmr or an unusual form of myositis.. But that she is having pain of aortic dissection and neck artery dissection. ( cannot explain why this dx would have pain relief with steroids though) A negative ta bx does not completely r/o arteritis.. Which as you know can be segmental. I would like to also see a muscle biopsy, though again the steroids will have affected the result. davis The pain was diffuse enough that I wasn't too concerned about a dissection, plus she did have a real temp recorded at 100. You are right about the bx. I had actually asked for a bilateral bx to increase the odds of catching it, but the surgeon only did one side. Link to comment Share on other sites More sharing options...
jmj11 Posted June 28, 2011 Author Share Posted June 28, 2011 initially I was concerned about small SAH(which I have seen start as neck pain and progress to h/a) as she never got that LP but steroid response makes PMR go to the top of my list. I didn't describe it in detail but her pain was her whole right sided trapezius muscle, into her shoulder with some on the left, then her neck and head. Maybe if it had just been her neck SAH might have made more sense. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 28, 2011 Moderator Share Posted June 28, 2011 ddx maybe - tick borne if endemic(would expect a higher ESR with this though) what about high T-spine HNP? to old for MS? (this is a question..) arm pain? thinking SVC syndrom, but pain is not a definin thing.... other mediastinal things...... mass or met? nope CXR okay...... hummmm any change in symptoms with position? unstable spondy? can't see discitis or infection with only a 44 and no WBC..... hummm on the thought of shoulder (that the Neuro brought up....) any shoulder issues? Link to comment Share on other sites More sharing options...
wcsmedic Posted June 29, 2011 Share Posted June 29, 2011 Initial impression is PMR with concomitant temporal arteritis. The marked resolution with the steroids tends to support this hypothesis. Link to comment Share on other sites More sharing options...
jmj11 Posted June 29, 2011 Author Share Posted June 29, 2011 I agree. We will wait and see what the rheumatology guys say, as well as the TA. I spoke to her last night. Still symptom free on 32 MG of Medrol. Link to comment Share on other sites More sharing options...
jmj11 Posted July 1, 2011 Author Share Posted July 1, 2011 UPDATE: Patient e-mailed us today with a "thank you" letter. Was seen by the rheumatologist yesterday and "confirmed the dx of PMR and TA." I'm not sure what this means, as far as I have not seen the bx results and I don't know if this is based on clinical symptoms, or bx findings. I will keep you posted when I know the final. Link to comment Share on other sites More sharing options...
andersenpa Posted July 1, 2011 Share Posted July 1, 2011 Nice work Mike Forward this to your "friends" at GHC. Link to comment Share on other sites More sharing options...
xxbowiexx Posted July 1, 2011 Share Posted July 1, 2011 right on, i'm glad to see that the diagnoses fits the presentation. Link to comment Share on other sites More sharing options...
jmj11 Posted July 6, 2011 Author Share Posted July 6, 2011 Oh yeah. I just posted another case but forgot to finish this one. Her rt sided TA bx was . . . POSITIVE for GCA. This is the first positive I've had in about 5 years. Link to comment Share on other sites More sharing options...
xxbowiexx Posted July 9, 2011 Share Posted July 9, 2011 that is indeed exciting Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.