Zebras!

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Mumpu

Mumpu

Burninator, MD
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Here are a few of the zebras I got to work up lately. Post your guesses and post your cases (keep 'em short!). Worst case scenario is that we all might learn something. Assume no significant PMHx, ROS, PE if none is mentioned.

1. 60 yo male with 6 months of nasal stuffiness and recent flank pain and hematuria.
2. 72 yo female who has blurry vision when she wakes up every morning, vision improves throughout the day.
3. 17 yo male with neck pain, stiffness, and bacteremia.
4. 45 yo female with rash and quotidian fevers. ANA neg, RF neg, sky-high ferritin.
5. 45 yo female with TNTC < 1 cm hypodensities throughout the liver on abdominal CT, asymptomatic.

I'll post the answers in a couple of days if no one gets them all. :cool:
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1. 60 yo male with 6 months of nasal stuffiness and recent flank pain and hematuria.--RCC
2. 72 yo female who has blurry vision when she wakes up every morning, vision improves throughout the day.--don't know--can't wait to hear what it is....
3. 17 yo male with neck pain, stiffness, and bacteremia.--?abscess?
4. 45 yo female with rash and quotidian fevers. ANA neg, RF neg, sky-high ferritin.--hemochromatosis?
5. 45 yo female with TNTC < 1 cm hypodensities throughout the liver on abdominal CT, asymptomatic.--don't know. (fatty liver?)
 
Mumpu said:
Here are a few of the zebras I got to work up lately. Post your guesses and post your cases (keep 'em short!). Worst case scenario is that we all might learn something. Assume no significant PMHx, ROS, PE if none is mentioned.

1. 60 yo male with 6 months of nasal stuffiness and recent flank pain and hematuria.
2. 72 yo female who has blurry vision when she wakes up every morning, vision improves throughout the day.
3. 17 yo male with neck pain, stiffness, and bacteremia.
4. 45 yo female with rash and quotidian fevers. ANA neg, RF neg, sky-high ferritin.
5. 45 yo female with TNTC < 1 cm hypodensities throughout the liver on abdominal CT, asymptomatic.

I'll post the answers in a couple of days if no one gets them all. :cool:
Click to expand...

1- Wegeners Granulomatosis

2- ectopic lens? Im stumped

3- meningitis. zebra? I dont know. needs more HPI for a zebra.

4- Adult stills disease

5- TNTC? whats that? help please
 
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Too numerous to count
 
5. 45 yo female with TNTC < 1 cm hypodensities throughout the liver on abdominal CT, asymptomatic.
Click to expand...

Since when do assymptomatic people get belly CTs?
 
1. Wegeners and I swear I thought of it before reading Mustafamond's post :)

2.Fuch's endothelial dystrophy or Sjogren's

3.Meningitis is the obvious answer but unless the source or organism is real weird it hardly counts as a zebra. More zebra like-retropharyngeal abscess. I've seen two that I thought for sure had meningitis.

4.Malaria-uriticarial and maculopapular rashes reported. Ferritin elevated as acute phase inflammatory response. Also: Rocky Mountain Spotted Fever, Babesiosis, Ehrlichiosis. A little description of the rash would help.

5.Not sure yet. Still thinking about it.
 
#5 - I bet they're those amoebic abcess thingies vs. congenital angiomas

Ahh, upon reviewing harrison's I see I was thinking of Entamoeba histolytica.
 
Maybe she was too sleepy in the morning to open her eyes wide enough to see well
 
i wanna realease a zebra in the hospital and have it run around for a while
 
Mumpu said:
1. 60 yo male with 6 months of nasal stuffiness and recent flank pain and hematuria.
2. 72 yo female who has blurry vision when she wakes up every morning, vision improves throughout the day.
3. 17 yo male with neck pain, stiffness, and bacteremia.
4. 45 yo female with rash and quotidian fevers. ANA neg, RF neg, sky-high ferritin.
5. 45 yo female with TNTC < 1 cm hypodensities throughout the liver on abdominal CT, asymptomatic.

I'll post the answers in a couple of days if no one gets them all. :cool:
Click to expand...

1. Wegener's - slam dunk
2. Fuch's
3. Disseminated Gonococcemia
4. Malaria
5. Something systemic but subclnical...multiple myeloma?

about 2, I actually Googled this a few weeks ago, and found this. Check the author. :laugh:
 
Doan wrote the presentation, he is a moderator here and a 'discussion' was held on the subject @ SDN, according to the U of Iowa site. I just thought it was humorous.
 
Idiopathic said:
1. Wegener's - slam dunk
2. Fuch's
3. Disseminated Gonococcemia
4. Malaria
5. Something systemic but subclnical...multiple myeloma?

about 2, I actually Googled this a few weeks ago, and found this. Check the author. :laugh:
Click to expand...
#5, I'm thinking you're on the mark, but I'm not exactly an authoritative opinion. ;)
 
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Idiopathic said:
5. Something systemic but subclnical...multiple myeloma?
Click to expand...
Multiple myeloma involving the liver is extremely rare, but not unheard of.

More history on #5 would be helpful especially why she had the ct. there are so many possible etiologies, we are just shooting in the dark without more information.
 
1. Wegener's.
2. Fuch's dystrophy -- I'm really impressed, this is the one I didn't expect anyone to get. :p
3. Lemierre's syndrome. Neck stiffness in a perviously healthy person a week or so after a sore throat (like viral pharyngitis or EBV) should prompt suspicion, cultures looking for anaerobes (Fusobacterium necrophorum is the most common pathogen) and a neck CT/ultrasound looking for jugular vein thrombosis and retropharyngeal abscess.
4. Adult Still's disease. It's a diagnosis of exclusion -- ANA neg, RF neg, very high ferritin is highly suggestive. I left out the classical salmon-pink evanscent rash because my patient actually didn't have it.
5. Caroli's disease. Biliary duct ectasia, asymptomatic in this patient but can result in outpouchings were gallstones form within the liver and can progress to Caroli's syndrome with liver fibrosis.

Great job everyone! Post some of your zebras!
 
too lazy to post the vignettes, but this week we had two Wegener's, one carcinoid in left mainstem bronchus, Candida empyema, hemangiopericytoma, acute rheumatic fever, and lung blastomyces.
 
we had a wegener's recently. it'll probably make grand rounds. i had a malignant insulinoma too, which was pretty cool.
 
forgot to add asymptomatic pulmonary artery saddle embolus. CT was textbook.
 
Idiopathic said:
Doan wrote the presentation, he is a moderator here and a 'discussion' was held on the subject @ SDN, according to the U of Iowa site. I just thought it was humorous.
Click to expand...

Oh... :idea:
 
Btw,may I ask, are these knowledge which pre-clinicals must know?

If they are..I'm in so much trouble :(
 
DireWolf said:
too lazy to post the vignettes, but this week we had two Wegener's, one carcinoid in left mainstem bronchus, Candida empyema, hemangiopericytoma, acute rheumatic fever, and lung blastomyces.
Click to expand...

Where was the hemangiopericytoma located? I recently ran across an intracranial one......
 
ericdamiansean said:
Btw,may I ask, are these knowledge which pre-clinicals must know?

If they are..I'm in so much trouble :(
Click to expand...

I wouldnt worry too much about it. When you go through path, you will hear about plenty of 'zebras' (pheo, carcinoid, struma ovarii, etc.) that you will be told that you will probably never see, but that are relevant for boards. Oddly enough, if you spend enough time at a larger hospital, you see quite a bit of impressive pathology.
 
Idiopathic said:
Doesnt seem possible.
Click to expand...

It was the right main pulmonary artery. My attending has only seen a handful of asymptomatic ones, hence the zebra.

What makes this case even more interesting is that fact that this guy had been diagnosed with ITP a few weeks earlier with subsequent splenectomy.
 
Boomer said:
Where was the hemangiopericytoma located? I recently ran across an intracranial one......
Click to expand...

It was the size of a baseball. Mediastinal: it was wrapped around the SVC and attached to the chest wall and pericardium. Pathology was sent to Italy.
 
Idiopathic said:
I wouldnt worry too much about it. When you go through path, you will hear about plenty of 'zebras' (pheo, carcinoid, struma ovarii, etc.) that you will be told that you will probably never see, but that are relevant for boards. Oddly enough, if you spend enough time at a larger hospital, you see quite a bit of impressive pathology.
Click to expand...

That is what great about radiology, I've seen most of the radiologic zebra's at least once. Seen several pheos, many carcinoids, a couple caroli's, etc.

As for the CT findings above, that is a very vague description and could have been many things including the more common liver cysts, mets from and undiscovered primary. There are many other things that could cause it. For caroli's there has to be a definite relationship to the biliary ducts, including the so-called central vessel sign (which is a misnomer since the vessel, which is a portal vein branch, is usually eccentrically located.

Never seen a hemangiopericytoma though.
 
This is discriminatory.....what about dem Giraffes?
 
Idiopathic said:
Doesnt seem possible.
Click to expand...
beleive me it is. one of my classmates had a case of this. it was diagnosed as CHF exacerbation several times until someone smart did a CT chest with contrast. easily missed, in fact.
 
wegener's makes it to your grand rounds?

on my 8 weeks of medicine we had 3 patients with it get hospitalized. didn't realize it was so rare.

later
 
DireWolf said:
It was the size of a baseball. Mediastinal: it was wrapped around the SVC and attached to the chest wall and pericardium. Pathology was sent to Italy.
Click to expand...

Mine was in a completely asymptomatic teen aged kid who got drunk at a party, got knocked out in a fight, came to ER, got the obligatory head CT, got his head cut open.....got lucky....
 
We had a pancreaticoblastoma in a 14-y.o. that was discovered only after patient's brother punched patient in the stomach and it wouldnt stop hurting.
 
1wegeners (but you should really have nephritic w/ upper AND lower resp sx)
2eaton lambert
3bacterial meningitis
4malaria
5echinococcus
 
that's kinda funny someone posted a site by andy doan- i worked with that guy in a lab when i was an undergrad- and he helped me with my application. nice guy.
 
12R34Y said:
wegener's makes it to your grand rounds?

on my 8 weeks of medicine we had 3 patients with it get hospitalized. didn't realize it was so rare.

later
Click to expand...
i guess it's pretty rare out here (100 miles north of chicago). *shrug*
 
12R34Y said:
wegener's makes it to your grand rounds?

on my 8 weeks of medicine we had 3 patients with it get hospitalized. didn't realize it was so rare.

later
Click to expand...

bull$hit.

Wegener granulomatosis occurs with a frequency of approximately 1 case per 30,000 individuals
 
not BS -- I saw 2 cases on my IM rotation...My school is kind of noted for caring for Wegener's patients, some of whom move to the area to get steady access to their providers...


So I believe 12R34Y...for better or worse.
 
thanks for backing me up. Wegener's i'm led to believe is not that uncommon in major academic medical centers. Afterall, we are a referral center for a huge geography.

i don't really have any reason to lie?

but, to say it again. wegener's 3 times in 8 week rotation.

later
 
Not sure how much of a zebra it is, but got a lady on our service right now with primary hyperaldosteronism. Came in with a K of like 2.5. Likely secondary to hypersecreting adenoma. Was missed at outside hospital 'cause they didn't / couldn't do an abdomen HRCT. We only caught it 'cause she's incarcerated and all those folks come to the University Hosp.
 
12R34Y said:
thanks for backing me up. Wegener's i'm led to believe is not that uncommon in major academic medical centers. Afterall, we are a referral center for a huge geography.

i don't really have any reason to lie?

but, to say it again. wegener's 3 times in 8 week rotation.

later
Click to expand...
It was bull$hit that you "found it hard to believe that Wegener's would make it to grand rounds."

If you were on a Hem/Onc or rheumatology service, it would be different. But three cases in 2 months on Gen-Med?

I just find it hard to believe that your residents were not excited about that.
 
I didn't say that the residents weren't excited, but the attending sure didn't care. General medicine (my team) managed him on the floor with little input. The staff seemed like it was pretty standard.

just my experience. not intended to cause any probs.

good luck.

later
 
My bad.
You probably go to a pretty tip program if you see cases like that all the time.
Ciao
 
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