We have ourselves yet another fresh mystery case yearning to be milked of its knowledge, so take a gander and see if you know what’s going on:
A 52 year-old undomiciled man comes to your ED complaining of 1 month of decreased appetite and fatigue. He says he constantly feels tired and not like himself. He also states he frequently finds bruises on his legs and gum bleeding. He reports recent ankle and knee pain with more difficulty walking. He denies fevers/chills, cough, chest pain, trouble breathing, N/V/D, or any other symptoms. He has never had these symptoms in the past. He otherwise does not provide any further history.
PMH: Denies
PSH: Denies
Meds: None
All: NKDA
SH: 3 beers/day, about 4 cigs/day, no other drug use. Lives on the streets.
ROS: Negative aside from above
PE:
Vitals – Normal
Gen – Nontoxic, lying in bed, alert and oriented
HEENT – Severe gingivitis with thickened gums and oozing blood. No palatal petechiae. Dry mucous membranes aside from the oozing blood. Mild conjunctival erythema. No nystagmus.
Skin – Mulitple non-palpable purpura and petechiae seen over extremities and trunk. Skin is thickened in many of the same areas. No other rashes are appreciated.
Extremities – large areas of ecchymosis and swelling over L ankle and R knee, tender to palpation, no warmth or signs of infection. Mild effusions in both affected joints.
The remainder of the exam is unremarkable, including a full neurologic exam
Labs:
CBC – WBC 8.0, Hgb 10.1, platelets 240
CMP – WNL
Coags – PT 10.1, aPTT 28
CXR – No acute findings
Extremity x-rays – Diffuse osteoporosis with no visualized fractures. No periosteal elevation
EKG – Normal sinus without any ST changes
So what do you think? Do you have an idea what might be afflicting this patient? If so, respond with your differential diagnosis, the further workup you would obtain, and what your management might entail. Best response gets this month’s glory. Happy sleuthing!
James Hassel
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2 Comments
edenkim · February 21, 2016 at 4:26 pm
Ddx for non-thrombocytopenic purpura/petechiae, include infectious, non-infectious, and congenital causes. in this case I’d say it’s probably not a congenital cause like a hemophilia if this has never happened until now. infection seems unlikely as he has no other symptoms and labs are unremarkable. it also seems like he has hemarthroses, which usually indicates trauma or coagulation disorder. top on my differential is scurvy, then vwf, autoimmune disorders and less likely leukemia.
i’d send ana, vwf, ristocetin, maybe do a smear, admit, and in the mean time start him on ETOH withdrawal protocol, supplement with vitamin c, thiamine and folate.
Amir · February 21, 2016 at 4:56 pm
Alcoholic and homeless
Gingiva and joint involvement
Depression symptoms
Diagnosis: Scurvy
D/d: Vasculitis and autoimmune disorders
Lymphoma/leukaemia
Ix: plasma, leucocyte or urinary vitamin c levels.
Rx: Alcohol deaddiction
Ascorbic acid 500mg 4-5 times a day for at least 1 week