For the Love of Science & Medicine Part II: Another PH case

[dinoiii]

For the Love of Science & Medicine Part II: Another PH case


For those new to the forum, this is how this works. I present a real case we see in IM/endocrine clinic, but stop short of saying what I chose to do for the patient and/or how mangement went. Instead I am giving you guys about a week to take a crack at it. For now, it is for fun...in the future, I hope to offer free product, etc... to the person(s) that get it correct. Think about it. Do some research if you have to and come back answering the questions I list at the bottom.

Have some fun. You can too see what it is like to be a clinician.

This was a great case and I so wanted to share it with you. Feel free to ask questions.

___________________________________________

CASE

TB is a 32 yr old man with no significant past medical history presents with a four-day history of generalized fatigue and malaise. He noticed these symptoms one day when he was at work and it got to the point that his co-workers were telling him "he looked like death." His boss finally sent him home against his desires.

He does note a slight right upper quadrant pain and some Left-sided chest pain that does NOT radiate (namely down left arm) and provides him with no diaphoresis (drenching sweat episodes).

He also notes transient periods of dizziness with head ache and diplopia (double vision). He denies myalgias (muscle aches) and/or arthralgia (joint aches).

He notes no allergies, but does imply that he uses some dietary supplements. On further quesitoning, his supplement use includes a 2-year STRAIGHT concurrent use of methyldienelone + MOHN in doses of 60mg A PIECE and you're worried about 10 or 20 mg of Superdrol - GEESH! His dose didn't necessarily surprise me as I have seen people with up to 120 mg of M1T alone.

He denies fever, chills, nausea, vomitting, diarrhea, constipation, blurred vision, heamaturia (blood in urine), hematochezia (blood in stool), clay-colored stool or melena (dark stool).

On physical exam, he is noted to have icteric sclera (yellow whites of his eyes), minor tenderness to palpation to RUQ of abdomen, negative Murphy's sign (pain on expiration of RUQ with concurrent compression). The remainder of his physical exam is unremarkable.

Lab Tests reveal a CPK (creatine kinase) of 8 times the normal limit. Liver function tests were surprisingly normal! His indirect bilirubin was up a tad.
Fasting Lipid Panel and CBC (complete blood count) were both NORMAL.
_________________________________________

QUESTIONS

(1) What additional labs would you want to investigate and why?

(2) What is the differential diagnosis?

(3) How would you treat this man?

[C-Los 21]

QUESTIONS

(1) What additional labs would you want to investigate and why?

(2) What is the differential diagnosis?

(3) How would you treat this man?

1) Although liver function test came back normal, I am not familiar if any "specific" test are available to rule out liver disease. His liver is having trouble breaking down the RBC and causing an increase in bilirubin. He also has reports of Juandice since he has "icteric sclera" (yellow whites of his eyes), which is another indication of faulty liver function.
2)Symptoms indicate liver malfunctions / complications IMO.
3)After more test are concluded and he has been diagnosed can we asses treatment.

Don't be too harsh on me, I am very curious in the outcome of this patient and want to see how wrong or right I am.

[Trans_Isomer]

1) I would suggest another liver function test be done, maybe a CT scan for the head pains/dizziness/diplodia. Check serum ammonia levels which if they are high, are suggestive of liver problems, kidney function test to check damge done by build up of toxins by steroid use. Blood test for alkaline phosphatase, which will be high in the case of abnormal function of biliary system, ECRP for biliary and pancreatic system

2) Creatine Kinase levels that high suggest muscle damage within the body, chest pain suggest maybe . Yellowing of eyes suggest some type of liver problems, maybe onset of liver disease. Prolonged exposure to chemical agents (MOHN & Methyldienelone?) can lead to these headaches the patient is experiencing.

The bilirubin test came back above normal, this suggest liver disease or a blocked bile duct. Increased bilirubin in the blood can cause the jaundice the patient is experiencing,
Tenderness to abdomen may suggest a build up of fluid (ascites)

-Patient may have Biliary stricture due to the patients many symptoms of it which include jaundice and abdominal pain, but his stools he denies are clay colored.

-Cholangitis may be the culprit as symptoms include pain in the right upper quadrant, jaundice

These im just going to throw these out there since the symptoms are almost all the same:
-Choledocholithiasis
-Glucose-6-phosphate dehydrogenase deficiency
-Idiopathic autoimmune hemolytic anemia
-Immune hemolytic anemia

3) Some further test may help rule out some of the above mentioned things, but some of the treatments for the above mentioned problems include
- Obstructed bile ducts may be drained by ERCP or by PTCA
- Maybe some anti-inflammatories

Im not a doctor but hopefully I kinda hit around the target. :)

[dinoiii]

No one else has ideas or do you concur with trans and c-los?

[mcsteveof2h2h]

I cant throw in any medical advice but that is absolutly unreal that the human body could with stand that kind of abuse i guess it says alot about the amazing adaptability of our bodies

I would agree and say that the signs would point toward massive liver destruction, i have no real medical knowledge (as listed above) but the course of action sounds about right for further tests on the liver

[dinoiii]

The liver. The human body's wonder organ and the only one with pure regenerative capacity. Think of it this way...we put so much crap into our bodies on a daily basis and the liver remains EXTREMELY resiliant.

It takes essentially years for alcoholics to develop liver disease.

Equal time frames for obese people to develop fatty livers.

And the list goes on...

[dinoiii]

All great thoughts so far. I love the thought process!!!

[Trans_Isomer]

Dinoiii, any update on this?

[Trans_Isomer]

^^^ bump for dinoiii

[NYCLeather]

Since the CBC is normal, it's unlikely he has hemolytic anemia.

I definitely want the Alk Phos if it wasn't a normal value in the LFT's. To have perceptible jaundice, you need a total bili in the 3 to 4 range (elevated).

It looks like there's significant muscle breakdown, but probably not enough to cause kidney damage, since 8 times normal would probably still have you under 1000.

I'd like a sonogram to start. I'd be concerned with cholestasis or a tumor since LFT's are normal.

[Wes Carnegie]

I want to reply to this thread, but I know nothing to say.

Wes

[dinoiii]

Author's Note: this was an actual case to be presented to a local chapter of the American College of Physicians this year!


Follow-UP tomorrow for the conclusion.

[dinoiii]

QUESTIONS

(1) What additional labs would you want to investigate and why?

- 200 was the labs “upper limit” of CPK – therefore, 1600 U/L was the number I was referencing above. It would still be imperative to get an isoenzyme panel. The isoenzyme panel revealed (BB- 0%, MB – 0%, MM – 100%, therefore “NORMAL” – denoting the CPK was likely musculoskeletal in nature). The one necessity would be to check if he was spilling myoglobin in the urine – so I had to get it sent out frozen. While his CPK was NOT as high as someone with the “prototyical” Rhabdomyolysis – it was necessity to check this status – especially considering the generalized fatigue + malaise. And renal falure has been noted in patients with CPKs as "low" as 5 times normal (we were at 8) which he obviously had surpassed. While waiting on the urine, a CXR would be done to consider his chest pain. This came back negative. It was followed with a Abdominal CT scan which too came back negative. Arteriography revealed multiple masses on BOTH the liver AND spleen (the largest liver mass 2 x 8 cm, the largest splenic mass to show was 0.8 x 1.2 cm). In the meantime, Ur Myoglobin came back at 54 ug / L (Normal = < 28)! A serum calcium level was later drawn, which proved to be low. NO evidence of clinical symptomatology (i.e. - Chvostek’s sign, etc...).


(2) What is the differential diagnosis?

The spilling of myoglobin put Rhabdomyolysis at the top of the list in the differential for the CPK level. Of course, it would have been difficult to distinguish between pretty intense exercise and the Rhabdo had there not been a urine myoglobin. Alternatively, he notes NO intramuscular injections or recent surgeries or seizures – making these items less likely in the differential – but again, it was the Ur myoglobin that cinched this diagnosis. An initial challenge because as it may be evident of pink to red urine, this is NOT always the case and WAS NOT here either.

But what about the multiple masses on arteriography studies?

This placed peliosis hepatis at the top of the differential. A wedged hepatic venography would later confirm the diagnosis.

[author's note: for description of peliosis hepatis, please see PCT: A Clinician's View Part II - Post-Cycle Supplements for elaboration under section entitled "neoplasms" - brief summary: blood-filled cysts seen with long term oral use of AAS]


(3) How would you treat this man?

Rhabdo:

A) Fluids: Crystalloid infusion was given to maintain a high urine output (> 3 - 4 mLs/hr).
B) Sodium Bicarbonate: We opted for urine alkalinization which has been proposed for the prevention of myoglobin nephrotoxicity, but its effectiveness has not been demonstrated conclusively. I sort of erred on the side of caution here. [author’s note: this is not protocol]
C) Continued monitoring for peripheral neuropathy – patient NEVER exhibited signs/symptoms.


Hypocalcemia (low calcium): This would essentially be watched clinically. It is not atypical of rhabdo cases and usually resolves spontaneously as the rhabdomyolytic condition is treated. As rhabdo resolved – sure enough…with it went the hypOcalcemia.

Liver / Splenic masses: Will have to monitor them over the course of a series of follow ups. Due to peliosis hepatis, it would be impossible to take any kind of aspirate (due to risk of hemorrhage) nor was it entirely necessary at this time. Because LFTs were normal, it would be hard to gauge when the next appropriate wedge venogram should be performed, but we did it at 4 months based on literature in diagnostics from the journal Radiology. Wedged venography performed at that time revealed morphologic improvement. Complete clinical resolution of RUQ and LUQ pain was also seen at 4 months. We would likely repeat at 8 months in follow-up series. Continued stability of LFTs would be imperative. The 8 month follow-up is February. Will keep you posted.

[kappaz]

Any updates?

[broken7]

His testies must have been as small a pea's
What I want to know is what was done to restore test production or if they have to go on hrt ?

[Voodoo]

whew, entirely over my head, I would have said jaundice with a side of see a doctor immediately ;)

[broken7]

His testies must have been as small a pea's
What I want to know is what was done to restore test production or if they have to go on hrt ?


bumping myself
Still wondering about this

[still alive]

hepatitis?

[dinoiii]

Sorry I haven't seen this being responded to (sometimes they get pushed to the top of my list when I search, other times it seems as though they remain burried)...


Any updates?

Overall, he is fortunate and as with most cases of peliosis hepatis, he did experience full recovery. Now, I have lost him to follow-up because I am no longer in Chicago...however, his last visit I was aware of was in June and he continues to report no exogenous use. This is, however, suspect as is anything on self-reporting systems of course. It is still what we have.



His testies must have been as small a pea's
What I want to know is what was done to restore test production or if they have to go on hrt ?

While I don't recall the complete physical exam in it's entirety, I assume "peas" may be a bit too small. ;)

He is not on HRT. His test function DID resume itself at 8 months in full! His testosterone (free and total) actually passed his pre-cycle status with continued therapeutic offerings (non-pharmacologic).


hepatitis?

No.

Hepat = liver

itis = iflammation

Hepatitis can have a couple major origins - if he did have fulminant hepatitis secondary to the use of exogenous substances, it would have been acute in nature.

Viral on the other hand would have had more resounding long-term effects (provided types B or C).

In either event, he had NEITHER.


D_