with David Skibbie, Inova Fairfax, on the Hot Seat
The Case
A previously healthy 13 yo M presents with vomiting and weight loss over the last month. He reports nausea and non-bloody, non-bilious emesis 3-5 times daily, often after meals. His oral intake has been decreased and he has lost 20 pounds (130 to 110 pounds) during this time. He has had daily, soft, formed stools with the exception of two loose stools the day prior to presentation. He reports decreased energy, dizziness, and malaise. He denies fever, night sweats, dysphagia, abdominal pain, hematochezia, and melena. No sick contacts. No recent travel, camping, insect or tick bites, or animal exposures. On confidential history, he denies new stressors and intentional weight loss. Review of systems reveals intermittent frontal headaches sometimes associated with seeing white spots. The headaches occur throughout the day and have never awakened him from sleep. He denies photophobia, diplopia, blurred vision, numbness, tingling, and weakness.
Physical Exam
You want to expedite this patient’s ED workup.
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Your labs return: CBC, electrolytes, liver function tests, and pancreatic enzymes are normal. UA is significant for specific gravity of >1.030, total protein 3+, and ketones 4+. After IV fluids his vital signs are HR 110, BP 124/76, RR 16, Sat 100
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About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
If his HR wasn't 129, this would be a mostly outpatient workup. I'm a little curious if his albumin is normal with 3+ protein in the urine. I would approach this one by system:
ReplyDeleteThink intracranial - brain tumor?
Think endocrine - thyrotoxicosis?
Think oncologic - pheochromocytoma?
Think GI/obstructive - bezoar, crohns, hepatitis
Think nutritional and/or psych
My approach would be to get neuroimaging and an abdominal XR and a slew of labs including inflammatory markers, TSH and plasma/urine catecholamines. Then bolus with saline and dextrose (agrawal style) to rehydrate and break his ketosis. I can't imagine a child this age would require admission unless he had persistent tachycardia or you had a high suspicion of something GI obstructive that required more immediate endoscopy. If his albumin is low, that points to either a systemic/chronic disease, something nutritional, or renal losses. so I would want to quantify his urine Pr/Cr ratio and see a creatinine. But ketosis and orthostasis points to intravascular depletion so I would try and fluid rehydrate, initiate an investigation, and coordinate out-patient follow-up to look for the zebras.
Interesting!
ReplyDeleteI had similar thoughts to Dave.
Using the above categories, increased ICP can cause these symptoms, though normal neuro exam (no coordination/CN/motor abnormalities). Need to check for papilledema on exam. Plain head CT in ED.
Endocrine: seems like a good illness script for endocrine abnormality, specifically Addison's disease. Need to look for increased palmar crease pigmentation (what an endo attending taught me) even w normal skin color. Seems that Na and K were normal, but would add a cortisol level to the labs.
Oncologic and rheumatologic diseases can both present more indolently, so a general screen of a blood count, inflammatory markers, liver/renal function would suffice after a good hx and exam.
GI: I was thinking mechanical obstruction, though no report dysphagia or abdominal distension. Start with AXR to look for obstruction.
Psych: anorexia nervosa is increasing in frequency in adolescent boys/men. Would ask whether wt loss worries him; ask about general performance (high achieving, driven). Given how acute his condition is, would not put this as high as earlier diagnostic categories.
So, agre with Dave, though my endpoint would likely be admission to coordinate GI and Endo consults-- his PEWS score is ok for the floor.
Just to add a few specific diagnoses to the GI category I would include "superior mesenteric artery syndrome" (SMA syndrome), eosinophilic esophagitis, gastroparesis, PUD/ H. Pylori, celiac dx (you never know), and cyclical vomiting. What argues for SMA syndrome (abdominal aorta compressing the duodenum) is the weight loss, nature of emesis and lack of neuro signs. What argues against is that SMA syndrome typically has significant associated abd pain and is more common in females. Keeping this differential in mind if other work up is negative one could consider (likely after admission) an abd CT, upper GI series, celiac lab testing, H. Pylori, and if all else negative EGD.
ReplyDeleteWell, probably the biggest clue that suggests this case will be something out of the ordinary is that we’re talking about it in this forum. Cases have contexts. Along these lines, one pearl to remember is this: if someone shows you a foot x ray during grand rounds, don’t look at it carefully-just blurt out “Lisfranc dislocation!”
ReplyDeleteThis is a subacute presentation, pointing away from the common causes of vomiting that we evaluate daily in the ED. The fact that the vomiting has remained non-bilious for a protracted period suggests against an intestinal process distal to the duodenum, especially when combined with the facts that he has not had abdominal pain and is nontender on presentation (and I am presuming that he is not distended on exam, although this is not specifically addressed in the PE). I don’t think we can dismiss such issues out of hand, but I would put them low on the differential. However, a progressive gastric outlet obstruction would fit. I would not feel compelled to make this diagnosis in the ED, as these entities generally do not require urgent treatment (aside from dealing with the child’s dehydration).
If the ED workup does not explain the issue, I would plan on admitting him for further evaluation to include a GI workup. In addition, this child needs a GU exam. I don’t have a high suspicion there, either, but it’s easily done so I would just include it on my initial exam. Finally, we should keep in mind the possibility of a toxic exposure.
I think the most concerning issue is the question of whether this child has increased intracranial pressure. Nausea and vomiting are cardinal signs thereof, and this child has had accompanying intermittent headaches and the unusual complaint of seeing white spots. This latter symptom might be considered a “positive sign” as opposed to a neurological deficit, and these generally are suggestive of migraine auras or rarely, seizures. However, papilledema symptoms may also include descriptions of “light flickering” or “arcs of light” in the visual fields. It might be helpful to inquire as to whether the symptoms are experienced in both eyes or just one, and whether there are any triggers such as coughing or head inversion.
There are many possible etiologies for intracranial hypertension. Generally, they can be separated into broad categories: space-occupying lesions (tumors, vascular malformations, acquired vascular entities including aneurysms, parenchymal hemorrhage, traumatic lesions, and non-communicating hydrocephalus secondary to the above) and communicating hydrocephalus (pseudotumor cerebri, acquired CSF outflow obstruction due to traumatic or spontaneous SAH, etc). My plan would be to investigate these possibilities with a noncontrast head CT, followed by an LP to evaluate CSF pressure if the CT scan were normal. MRI may be necessary at a later time, but the purpose of the Head CT is to help us assess the safety of LP, and it is an adequate study for nearly all situations.
Thanks for the chance to participate, and Happy Thanksgiving to all!
This is an interesting case and I'd be interested to know the outcome. Interesting that electrolytes normal despite the vomiting.
ReplyDeleteI'd try and investigate as an outpatient if possible.