with David Skibbie, Inova Fairfax, on the Hot Seat
Case edited by Emily Willner, Children’s National
The Case
This was a case of a 13 yo boy with vomiting and a 20 lb weight loss over the last month. He has continued to have stools and also reports dizziness and malaise. For the complete case presentation, click here.
Here’s how you answered our questions
What additional test do you think will be most useful in narrowing your broad differential?
[Greater than 3 years PEM experience] n=12
[Less than 3 years PEM experience] n=8
A lot of people wanted head imaging as their most useful test. A larger percentage of the more experienced group wanted to wait for labs before further testing compared to the less than 3 years of experience group. A larger portion of the less than 3 years of PEM experience group wanted abdominal imaging compared to the greater than 3 years group.
Labs return: CBC, electrolytes, LFTs, and pancreatic enzymes are normal. UA is significant for a 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, O2 sat 100%
Would you perform a head CT in the ED?
[Greater than 3 years PEM experience] n=12
[Less than 3 years PEM experience] n=8
In this question, the majority of PEM providers with more than 3 years of experience would perform a head CT in the ED while the less than 3 years of experience group had also considered waiting for the MRI or not doing one in the ED at all. Why the discrepancy? Also, a significant proportion of people would get abdominal imaging before head imaging for this patient. What were we hoping to find with the abdominal imaging?
Would you perform any abdominal imaging at this time?
[Greater than 3 years PEM experience] n=13
[Less than 3 years PEM experience] n=8
75% of respondents with greater than 3 years of clinical experience would get an abdominal x-ray next while only a quarter of those with less than 3 years of experience would get an abdominal x-ray. These providers instead considered ultrasound more frequently and also would have ordered an abdominal CT about as frequently. One person said they wouldn't get any abdominal imaging at all. What are some reasons for the seasoned people clearly preferring abdominal x-ray?
Clinical Pearls
On a structured approach
“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.” –Dave Mathison, Children’s National
On the diagnostic considerations
“Think intracranial - brain tumor?
Think endocrine - thyrotoxicosis?
Think oncologic - pheochromocytoma?
Think GI/obstructive - bezoar, crohns, hepatitis
Think nutritional and/or psych”
-Dave Mathison, Children’s National
“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.” –David Skibbie, Inova Fairfax
“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.” –Jennifer Chapman, Children’s National
“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.”-David Skibbie, Inova Fairfax
“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.” –Mordechai Raskas, Children’s National
On disposition
“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.” –Dave Mathison, Children’s National
“So, agree with Dave, though my endpoint would likely be admission to coordinate GI and Endo consults-- his PEWS score is ok for the floor.” –Jennifer Chapman, Children’s National
“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.” –David Skibbie, Inova Fairfax
“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.” -Mordechai Raskas, Children’s National
Click here to read their comments in full
From the Hot Seat
by David Skibbie
Inova Fairfax
Well, 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!”
This 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.
Denouement
by Erin Augustine
Children’s National Medical Center
After admission to the hospital, final review of the patient’s head CT by an attending neuroradiologist was normal. A complete abdominal ultrasound was unremarkable. A diagnosis of thyrotoxicosis was made after the results of his thyroid stimulating hormone (TSH) returned at below 0.01mcunit/mL (normal 0.52-5.08mcunit/mL). The patient had an elevated free T4 and T3 at 8.09ng/dL (normal 1-1.6ng/dL) and 402ng/dL (normal 60-228ng/dL), respectively. His final diagnosis of Graves’ disease was confirmed after he was found to have elevated thyroid stimulating immunoglobulins at 365% baseline (normal is less than 140% baseline) and thyroid peroxidase antibodies at 259intl.units/mL (normal is less than 35intl.units/mL). Re-examination after the diagnosis did not reveal a palpable thyroid, thyroid bruit, exophthalmos, or myxedema. The patient continued to deny symptoms of behavior changes, heat intolerance, nervousness, palpitations, sweating, and deteriorating school performance. He was started Methimazole and discharged after two days when he was tolerating oral intake without emesis.
One month after discharge, the patient had regained 6kg. His free T4 had significantly decreased to 0.96ng/dL. His TSH continued to be suppressed at less than 0.01mcunit/mL. His thyroid stimulating immunoglobulins and thyroid peroxidase antibodies remained elevated at 404% baseline and 356intl.units/mL, respectively. His dose of Methimazole was decreased and he continues with regular endocrine follow-up.
The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.
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