Moderator ventana Posted October 21, 2011 Moderator Share Posted October 21, 2011 So have a patient that has stumped myself and 3 of my attendings.... thoughts on Ddx and who to send to? 58yr white female - european descent, heavby set, nonsmoker,does eat red meat occasionally, mother had some type of 'cycsts on her kidneys' that resulted in RF and dialysis last 3 years has had "seasonal allergies" bad enough that she has convinced one of the doc's to give her solumedrol 125 injection and this makes her all better (gets twice per year now spring and fall) came in last week with nasal congestion, fatigue, runny eye, rhinitis and typical allergic s/s after long talk we agreed on a medrol dose pak with 4mg tabs which is 6,5,4,3,2,1 tabs a day decreasing came back in yesterday saying getting worse but was 75% better still c/o allergy syndrom of upper resp and a slight cough I am thinking something is not right and patient is pissed that I have not just given her a shot....... start to research - last summer anemic to 5.9!! negative GI work up(upper and lower) and screeen for Celiac, saw Hematology who off a peripheral smear Dx iron def anemia (I thought Iron Def only would take you to around 8 typically) started iron and she did retic but only has gotten to about 7 hgb.... vitals normal but HR was high 90's and for a heavy set female I was surprised with the intensity of the heart beat when palpate PMI - felt more like a skinny endurance athlete.... needless to say I am convinced this is not iron def anemia, I have her seeing an allergist (I had done a screening RAST test and IgE both of which were negative/normal) to hopefully R/O allergy. I have this hunch that she has some type of RBC loss due to autoimmune (ESR was 39) process but my doc's just shake head and say who knows...... Already seems Heme and I am going to talk to him today and try to convince for a bone marrow - so seeing allergist to r/o allergies, see's heme already but does have an elevated ESR at ~40, FMH of strange renal failure What am I missing???? Addisons, adrenal, autoimune, inflamtory, suspect solumedrol is effective due to hemopoetic effect not jsut antiimflamatory effect, where are her RBC's going..... no splenomegally on exam but central obesity... TSH runs around 1..... scratching my head..... Link to comment Share on other sites More sharing options...
GeneValgene Posted October 21, 2011 Share Posted October 21, 2011 yea, something fishy. you have the rest of the anemia w/u (e.g. retic, ferritin, tibc, mcv, hct, rdw, transferrin, fe, b12, folate rbc, etc. etc.)? strange that hematology has already worked it up and hasn't said too much. and you said heme said periph smear was unremarkable...hmm...i would think a bone marrow makes sense. i would have hematology take a second look... your cardiac exam along with the pt hx sounds c/w high output heart failure from chronic anemia curious to what you guys figure out :) Link to comment Share on other sites More sharing options...
SocialMedicine Posted October 21, 2011 Share Posted October 21, 2011 if it is autoimmune expect a large reticulocyte count and elevated LD. Any concern over kidney etiology of low RBC ? Check EPO? Her symptoms sound like a common cold vs. allergies. I dont think she needs that injection again. How about zyrtec at price costco. She can get a years supply for like 20 dollars. Concerned about heart failure? You could order an ECHO ... does the EKG suggest hypertrophy? CXR might be a nice idea , lower cost and invasion. I would probably order CXR, EKG, Anemia blood work and either treat for infection or allergy depending on how the symptoms looked once I get this info back. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 21, 2011 Author Moderator Share Posted October 21, 2011 she will not tolerate any form of antihistamines - all of them "knock her out" didn't go down the cxr/ekg line but think I need to - to this point figured it was just reactive to anemia no more steroid injections (I never gave her one) labs: h:h 8.4/27.7 down from 11.5 at the heme office 6m ago retic high at 6.4, plat up also at 453 ferritin low at 9 lft kidney panel normal tsh 0.41 spoke to heme (less then helpful) wants to confirm she is taking iron, then redo GI work up - as she did get up to ~12 hgb he thinks this is still just iron def (loss most likely if taking iron or iron depletion if not) he said ESR elevated due to anemia Link to comment Share on other sites More sharing options...
jbwpac Posted October 21, 2011 Share Posted October 21, 2011 needs stool hemocults, ^EGD and colonoscopy......... Link to comment Share on other sites More sharing options...
bradtPA Posted October 21, 2011 Share Posted October 21, 2011 What's the bilirubin? Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 21, 2011 Author Moderator Share Posted October 21, 2011 What's the bilirubin? normal at 0.6 Link to comment Share on other sites More sharing options...
cinntsp Posted October 22, 2011 Share Posted October 22, 2011 Mcv/mch/rdw? What was the TIBC? Link to comment Share on other sites More sharing options...
SocialMedicine Posted October 22, 2011 Share Posted October 22, 2011 3 rd generation anti histamines cane sometimes have less SE profile. What about intranasal steroid (nasonex) or antihistamine (astelin) they offer low SE potential and may provide control of Sx. Her other Sx sound much more concerning. What is her colonoscopy history ? Does she use medicines or have behaviors at risk for ulcer ? Iron deficiency and anemia in a post menopausal woman of age 58 w/o chronic disease is real concerning. It is fine to start her on iron but thats not sufficient enough. We need to determine why she is losing iron. The GI tract sounds like a possible source. The high retic count ... could we have autoimmune without an elevated LDH? I dont think so. I also dont think the retic count is that high. Right? I forget the normal range but recall a recent hemolytic anemia where it was MUCH higher than that. Ferritin is an acute reactant .... if you want to be certain iron loss is an issue we could do TIBC but yea im sure it is reflective of things and this will not yield much. Link to comment Share on other sites More sharing options...
Doc Savage Posted October 23, 2011 Share Posted October 23, 2011 Bone marrow biopsy sounds good to me... chronic idiopathic myelofibrosis is possible, as well as many other myeloproliferative disorders. I am just a student... but I love to learn the why and why not of medicine. If I am in left field let me know, but please tell me why. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 24, 2011 Author Moderator Share Posted October 24, 2011 Mcv/mch/rdw? What was the TIBC? mcv normal 94.7 Ferritin low at 9 TIBC high at 453 tranferrin high at 351 % Sat low at 12 RDW high at 17.3 WBC 6.8 normal plt high at 453 Iron Def should yield low MCV and she is normal, does have a low Ferritin but with a normal MCV this means their mich be multifactorial or due to the Retic and higher RDW (body is making RBC's) is is skewed.... as for antihistamines - she say ALL knock her out, bendaryl, zyrtec, loratidine, desloratine, and allegra all do it Did have a fully negative UGI and colonoscopy 18m ago when she was at 5.9 for HGB I did not check LDH nor a urobilogen in the urine.... ???? where does LDH play into autoimune? Link to comment Share on other sites More sharing options...
cinntsp Posted October 24, 2011 Share Posted October 24, 2011 ???? where does LDH play into autoimune? LDH goes up with intravascular hemolysis but you said the bili was normal. What about a haptoglobin? I don't know...just going off of the lab values looks like there is more than one thing going on. Was a peripheral smear reviewed this time(you only mentioned last summer)? Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 24, 2011 Author Moderator Share Posted October 24, 2011 LDH goes up with intravascular hemolysis but you said the bili was normal. What about a haptoglobin? I don't know...just going off of the lab values looks like there is more than one thing going on. Was a peripheral smear reviewed this time(you only mentioned last summer)? no smear with this one - going to send her to GI for another go...... I agree something is fishy.... Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 24, 2011 Share Posted October 24, 2011 What are you considering? If truly neg GI upper/lower scope (with adequate prep and good visualization and neg bx) within 18 mos I would be hard-pressed to repeat scope just yet...but I like the autoimmune angle. Heme should have done this but if not, repeat CBC/ man diff with peripheral smear AND PATH REVIEW. Hb electrophoresis. Consider tagged RBC scan before BM aspirate. I do think nl LFTs makes RBC destruction seem unlikely. Interesting case. (and I too would try to sweet-talk her into nasal steroids. I've tried them all and my personal opinion is Nasacort AQ is probably the gentlest though I think Nasonex is fantastic and effective). L. Link to comment Share on other sites More sharing options...
boomersooner34 Posted October 24, 2011 Share Posted October 24, 2011 I'm just a student and could be way off, but what about trying a leukotriene inhibitor like singulair for her allergy sx. Also, you said she has a FMH of strange renal failure and a PMH of "cysts" on her kidneys. Was that previous condition ever diagnosed as/or has she (or a family member) ever been diagnosed with Polycystic Kidney Disease? It is hereditary. PKD resulting in kidney damage could cause decreased EPO production which could lead to the anemia. Just a thought. If I'm way off, please explain where my thinking went wrong Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 24, 2011 Author Moderator Share Posted October 24, 2011 I'm just a student and could be way off, but what about trying a leukotriene inhibitor like singulair for her allergy sx. Also, you said she has a FMH of strange renal failure and a PMH of "cysts" on her kidneys. Was that previous condition ever diagnosed as/or has she (or a family member) ever been diagnosed with Polycystic Kidney Disease? It is hereditary. PKD resulting in kidney damage could cause decreased EPO production which could lead to the anemia. Just a thought. If I'm way off, please explain where my thinking went wrong singulair is a reasonable thought with PKD you would expect to see a bump in renal function at the same time as an EPO decrease - actually the EPO trails behind functional loss and would not expect a normal BUN/CR and not making normal amount of EPO - as well if this is the cause of the problem you would not expect her to retic with new RBC's with exposure to Iron.... good thoughts though.... Link to comment Share on other sites More sharing options...
boomersooner34 Posted October 24, 2011 Share Posted October 24, 2011 Oops. I didn't see that she had normal kidney function...skipped right over that part. Sorry about that and thanks for the advice and explaining the reasoning Link to comment Share on other sites More sharing options...
Doc Savage Posted October 27, 2011 Share Posted October 27, 2011 Bone marrow biopsy sounds good to me... chronic idiopathic myelofibrosis is possible, as well as many other myeloproliferative disorders. I am just a student... but I love to learn the why and why not of medicine. If I am in left field let me know, but please tell me why. I guess I am in left field, everyone ignored me. I always wanna chase the zebras... Well I would be interested in how the case turns out. It is a great learning experience. Is there a section for Zebra discussion and tough case files that is a sticky thread??? Maybe we could move this thread there or start one if it does not exist. Link to comment Share on other sites More sharing options...
delco714 Posted October 27, 2011 Share Posted October 27, 2011 I agree with astelin (intranasal). Even allegra makes her tired? Low dose of nasal steroids? did you try singulair (montelukast) with at least a month for it to kick in? thinking r large colon cancer with insidious progression? Funny enough I was thinking celiac sprue too. what screening test was done? Biopsy is definitive, whereas blood has enough false positives and negatives. Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 28, 2011 Share Posted October 28, 2011 Have you ever TRIED Astelin NS or azelastine eyedrops? DROWSIEST stuff ever. Plus it tastes horrendous...truly awful. Effective, yes, but I was so sleepy I hardly noticed. Just saying. I agree with astelin (intranasal). Even allegra makes her tired? Low dose of nasal steroids? did you try singulair (montelukast) with at least a month for it to kick in?thinking r large colon cancer with insidious progression? Funny enough I was thinking celiac sprue too. what screening test was done? Biopsy is definitive, whereas blood has enough false positives and negatives. Link to comment Share on other sites More sharing options...
Hemegroup Posted October 29, 2011 Share Posted October 29, 2011 I'm just a student and could be way off, but what about trying a leukotriene inhibitor like singulair for her allergy sx. Also, you said she has a FMH of strange renal failure and a PMH of "cysts" on her kidneys. Was that previous condition ever diagnosed as/or has she (or a family member) ever been diagnosed with Polycystic Kidney Disease? It is hereditary. PKD resulting in kidney damage could cause decreased EPO production which could lead to the anemia. Just a thought. If I'm way off, please explain where my thinking went wrong Good thoughts. Link to comment Share on other sites More sharing options...
delco714 Posted October 29, 2011 Share Posted October 29, 2011 Yes. I had,zero lethargy with good anti histamine effects. as an individual I don't get tired by from anti histamine like most.. I like astelin personally. It tastes bad because you probably sniff it up. Just spray don't sniff. That is proper technique. If you did this, then I apologize! Link to comment Share on other sites More sharing options...
cecilia Posted October 29, 2011 Share Posted October 29, 2011 could she be an alcoholic? (severe anemia)...and that's why all antihistamines knocks her out? Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 29, 2011 Share Posted October 29, 2011 Alcoholism tends to result in macrocytic anemia and if I recall correctly she was significantly microcytic (think Fe-def, thalassemias etc). I don't see the connection between alcoholism and susceptibility to sedation with H1 blockers. Some folks just don't tolerate antihistamines. As for the Astelin comment above, to each her own ;) I couldn't tolerate the stuff...give me a 2nd gen H1 blocker and nasal steroid any day...much better tolerance. Not much success at all with leukotriene inhibitors for me but they seem to help some folks. I might be cautious about them for someone with a suspected blood dyscrasia that's not yet understood although I don't think Singulair has the same problems Accolate did in that arena. I like the celiac disease thinking...make SURE if she gets scoped again they get MULTIPLE small bowel bx (not just a look around) to rule out. Serology for Celiac dz IME is almost worthless except anti-gliadin Ab sometimes (disclaimer: I haven't practiced IM in nearly 7 yr and we just don't order these things in EM. I really miss IM...can you tell?!) ;) Keep us updated Ventana...curious. L. could she be an alcoholic? (severe anemia)...and that's why all antihistamines knocks her out? Link to comment Share on other sites More sharing options...
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