Oct 8, 2014 - Systemic malignancy and vasculitis with central nerv- ous system and .... Among these, eosinophilic granulomatosis with polyangiitis (EGPA).
SOLVING CLINICAL PROBLEMS IN BLOOD DISEASES
AJH Educational Material
A JH
A physician or group of physicians considers presentation and evolution of a real clinical case, reacting to clinical information and data (boldface type). This is followed by a discussion/commentary
All systems red Paras Karmacharya,1* Anthony A Donato,1 Madan Raj Aryal,1 Ranjan Pathak,1 Michael Goonewardene,1 and Peter Valent2
A 69-year-old female presented to the emergency department with a 1-week history of low-grade fever, progressive dyspnea on exertion, fatigue, and confusion. She denied headache, nausea, vomiting, weakness, numbness or tingling in her extremities, orthopnea, chest pain, or swelling of her legs. Although previously very active, she had become homebound over the same duration and was not able to perform her daily activities. Her medications included mometasone-formoterol inhaler and zafirlukast for chronic obstructive lung disease and ibuprofen as needed for joint pain for the past 2 years, none of which was newly prescribed. She had a history of allergy to nonspecific environmental allergens. She denied any history of rash or recent travel. Confusion is a common symptom in the elderly and can have multiple etiologies, including polypharmacy, infections, hypovolemia due to medications or poor oral intake, electrolyte imbalances, cardiovascular problems, allergies, and central nervous system lesions. However, the presence of low-grade fever, dyspnea on exertion, and fatigue suggest the presence of a systemic disease with multisystem involvement. Given the relatively acute onset of her symptoms, an infectious or inflammatory etiology seems likely. Common multisystem infections that can affect cardiac and neurologic systems should be considered, including subacute bacterial endocarditis which can cause peripheral embolization to the central nervous system. Bacterial pneumonias can explain her dyspnea as well as her confusion due to delirium, however, her subacute illness time course and absence of an underlying dementing illness make this scenario less likely. Alternatively, noninfectious etiologies such as acute pulmonary embolism, diabetes mellitus, or exacerbation of her reactive airways should be considered. However, confusion is atypical with these conditions unless accompanied by shock or in the presence of a systemic thrombotic condition. Systemic malignancy and vasculitis with central nervous system and pulmonary involvement would also be a consideration here, although unlikely with her acute presentation. Her past medical history was significant for two episodes of transient word-finding difficulties and left facial droop 1 year prior with normal magnetic resonance imaging (MRI) findings. Her family history was negative for any cardiopulmonary or immunological disorders. Vital signs, including orthostatic blood pressures, were normal. On examination, she appeared confused, sluggish, and slow to respond to questions, but demonstrated no focal neurological deficits. She did not have any rashes or palpable lymph nodes. She had bilateral expiratory rales. The cardiovascular
examination was normal including absence of jugular venous distension or pedal edema. Her previous history of transient ischemic attacks and sudden onset makes a cerebrovascular event a possibility. However, the presence of constitutional and cardiopulmonary symptoms, as well as the lack of focal deficits in the distribution of a single vascular territory should lead us to broaden our differential diagnoses. Her exam is not consistent with congestive heart failure. Patient’s electrocardiogram showed nonspecific ST and T wave changes. Troponin level was 15 ng/ml (
