Autumn is here and hot off of CPC, COtM surges forward. Get ready to crunch those brains and be a diagnostic hero.
A 34 y/o M presents to the ED with 3 days of watery diarrhea with small amount of mucous, fever, chills, cough with clear phlegm, chest pain, and malaise. All symptoms started around the same time. Chest pain is non-exertional, substernal, aching, non-radiating, not worsened with a cough. No abd pain or N/V, no leg pain or swelling. He is on vacation in NY, originally from France, felt fine prior to travel. No sick contacts.
PMH: Depression
Meds: Sertraline
SH: No toxic habits
VS: 110/84, HR 90, RR 16, Temp 101.0F orally, 98% on RA
Exam reveals moist MM, normal CV/respiratory exams, no reproducible chest pain, soft nontender abdomen, normal neuro exam, no LE edema or calf tenderness, small amount of blood on glove from rectal exam with dark brown watery stool. All other exam findings are negative.
CBC: WBC 22 with 90% neut, Hgb 12.1, platelets normal
CMP: Normal
Trop: 0.145
CK 166
Normal lactate and venous pH
EKG (no prior):
CXR: Question small LLL effusion, otherwise no consolidation
Bedside echo in ED: depressed systolic function, no pericardial effusion, valves appear normal.
Your task, if you choose to accept it, is as follows:
- What is in your differential?
- What further workup would you do?
- What therapies (if any) would you start?
- What is your most likely diagnosis?
Good luck and happy sleuthing!
James Hassel
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2 Comments
Rithvik Balakrishnan · October 13, 2015 at 2:21 am
Ddx: bacterial myocarditis (lyme disease, rheumatic fever, Borrelia, Brucella), Viral (Coxsackie, other enteroviruses, Parvovirus B19), autoimmune myocarditis
Work-up: HIV test, Blood cultures x 2, myocardial biopsy
Therapy: Supportive care at this point
Dispo: Consult CCU, given fast deterioration of patient, he may require transportation to a transplant center
Discussion:
Clinical picture most suggestive of infectious etiology (patient has leukocytosis with neutrophilia, but that could also represent early phase of leukocytosis). Chest pain, decreased systolic function, elevated Troponins (and CK), EKG findings (diffuse ST elevation), and LLL effusion suggestive of myocarditis/pericarditis. Bacterial causes of myocarditis/pericarditis are rare without underlying immunodeficiency (though patient could certainly have an underlying immunodeficiency, nothing in his history is suggestive of that). That leaves viral myocarditis (again, neutrophilia could represent early stage of leukocytosis) with leading candidates including Coxsackie virus (A notable contribution of upstate New York), but also other enteroviruses.
Thus, for the work-up, I would perform an HIV test, draw blood cultures x 2 (evaluate for possible bacterial pathogen), perform a myocardial biopsy.
At this point, I would give the patient supportive care only, though the temporal nature of symptoms (decreased systolic function within 3 days) is worrisome. I would strongly consider consulting the CCU, and trying to transfer the patient to an outside facility with transplant services.
edenkim · October 16, 2015 at 5:34 pm
Agree with Rithvik’s workup and it’s most likely viral myocarditis, given the time course, lack of cutaneous findings, . but I would also add to the ddx: serotonin syndrome (very unlikely without clonus or hypertonia on exam), toxic ingestion, hyperthyroidism (i doubt you would do two hyperthyroid cases in a row), q fever (if I recall correctly is some sort of association with France and q fever), chagas dz (dont think it’s endemic to France and no cutaneous manifestations or symptoms really suggestive of megaesophagus/colon)
Workup: get more history regarding exposures, get an ID consult as well, also send ANA, utox, tylenol and ASA level, TFTs, BNP, mag level, likely TTE/TEE inpatient
EKG is hard to see well but shows irregular rhythm @ ~90 bpm, normal axis, QRS widened, PR interval appears normal, QTc appears prolonged, LBBB pattern, possibly multiple p wave morphologies. does not meet sgarbossa’s criteria for STEMI
Tx: I would have a low threshold to start antibiotics for possible bacterial myocarditis. likely empirically start ceftriaxone or doxycycline for the arthropod borne myocarditises +/- rifampin for brucellosis, or consider albendazole/nifurtimox for chagas if history is more suggestive of that. Start pressor support or IABP if needed.