The Case
A 64 year old female is brought in by her sister with a variety of chief complaints.
1. Blurry vision – acutely worse this morning.
2. Worsening shortness of breath, especially on exertion and on lying flat for 3 weeks. She has also developed bilateral lower extremity edema during this time period.
3. Not acting like herself, more lethargic over the last two days.
4. Paresthesias to her bilateral hands over the last 2 days.
The sister does not know the patient’s past medical history exactly, but remembers that she had something wrong in her blood involving her “globes”
ROS + for mild cough, mild abdominal pain, and mild headache
Denies fevers, chills, chest pain, weakness, hematuria, dysuria, nausea, vomiting, neck stiffness, recent travel, sick contacts, rashes, a history of eye problems or any other complaint.
VS HR 101, RR 25, Temp 100.1 F oral, O2sat 92%
PE is normal except for
Bilat crackles 2/3 way up back
Bilat 2+ lower extremity edema
Lethargic but arousable.
Neuro exam is difficult as the patient is unable to properly follow instructions, but is grossly negative for acute findings.
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andygrock
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3 Comments
ablumenberg · May 3, 2015 at 3:11 pm
This is a strange presentation. No clear diagnosis springs to mind.
Signs of CHF + acute blurry vision + altered mental status + paresthesias
Hypoxia, low grade temperature, tachy to 101. Non specific aches
Caveat that hypoxia not typical of CHF and raises concern for primary or secondary lung pathology. Paresthesias may be related to hypoxia-driven hyperventilation and resulting alkalosis.
Differential:
Endocarditis – CHF, fever, altered mental status, vision changes. TTE/TEE in the acute setting. Blood cultures and basic labs. Broad antibiotics with coverage for mouth flora and MRSA.
Thiamine deficiency – can cause wet beriberi explaining the CHF picture, dry beriberi explaining the paresthesias, and Wernicke encephalopathy explaining the vision changes and altered mental status. Give thiamine with dextrose.
Wegener’s disease – the “chf” picture may be pulmonary/renal pathology. Unlike Goodpastures, Wegener’s often has effects on the upper respiratory tract and could conceivably cause vision changes.
Evaluate for common diseases presenting uncommonly such as: UTI, uremia, anemia, pneumonia, thyroid.
Other possible diagnoses:
Ovarian cancer – may cause limbic encephalitis and pleural effusions.
Lupus – pneumonitis, ophthalmitis, cerebritis
Syphilis
Anticholinergic toxidrome – chf, ams, tachycardia, elevated temperature
CO poisoning
B12 deficiency – High output CHF due to anemia, paresthesias, decreased cognitive ability
ptepler · May 4, 2015 at 1:40 pm
I have very little to add to the above presentation except given the pt’s vague pmh and ams with parasthesias and belly pain in ros makes me think about porphyria, it may be worthwhile to get a urine porphyinbilnogen and heme consult for hemin/d10 (though if the pt is also in chf exacerbation this presents a bit of a problem, we need to confirm the pt’s volume status and etiology of lung path as well)
ablumenberg · May 13, 2015 at 9:23 pm
Definitely hyperviscosity syndrome.