Name:
A 75-Year-Old with Abdominal Pain and Nausea
Description:
A 75-Year-Old with Abdominal Pain and Nausea
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T00H07M41S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. ♪ (music) ♪
CATHY: Welcome to Episode 45: A 75-Year-Old with Abdominal Pain and Nausea.
CHARLIE: Okay, here's the question. A 75-year-old man underwent diagnostic coronary angiography after an abnormal stress test. Arterial access was obtained easily in the right femoral artery, and the angiography was completed with 35 mL of contrast dye. Fortunately, while he did have diffuse mild atherosclerosis, there were no significant coronary stenoses identified and none that required intervention. Now, seven days later, the man presents to the emergency department with abdominal pain and nausea over the past couple of days.
CHARLIE: He's reported also that his urine output has been dropping off. Physical examination reveals a slight fever of 38.3°C and otherwise normal vital signs. His lungs and his heart are normal, but his skin exam shows livedo reticularis on his lower extremities. His laboratories are notable for a creatinine of 2.7 mg/dL, and notably, it was previously 1.1 prior to the procedure. His white blood cell count is 10,500, with 21% eosinophils and an erythrocyte sedimentation rate is 92 mm/h.
CHARLIE: The question's going to ask, "What is the most likely diagnosis?" And the options are: A. acute interstitial nephritis; B. atheroembolic renal disease; C. Churg-Strauss syndrome; D. contrast-induced nephropathy; or E. hypereosinophilic syndrome.
CATHY: Okay, this is a good one, because he has a lot going on. So, let's go through the case and talk about the relevant findings.
CHARLIE: Okay, where do you want to start?
CATHY: Well, so let's start with a summary of what we heard so far. So, we have a 75-year-old man who had an abnormal stress test which prompted coronary angiogram, and then a week later he presents with acute kidney injury, fever, eosinophilia, and an elevated ESR. The angiography was negative, and during the procedure he received 35 mL of contrast. Now, any time an elderly patient gets contrast, it makes you think of contrast-induced nephropathy as the cause of his renal failure, but his baseline renal function was normal and the risk of contrast-induced nephropathy in that setting is really quite low.
CATHY: Add to that that he only got 35 mL of contrast, which really isn't that much. The other factors in this case that go against this being contrast-induced nephropathy are the systemic symptoms, because in CIN you wouldn't have any of those, and also the time course doesn't fit. Usually, in someone who does have contrast-induced nephropathy, you'll see a rise in the creatinine in the first couple of days.
CATHY: Seven days after contrast exposure, which we hear about in this case, the creatinine really should be back to normal.
CHARLIE: Okay, so it sounds like you've ruled out Option D, contrast-induced nephropathy. What do you think about the rest of the case? And, in particular, what about these systemic symptoms and the skin findings?-- because that's not common after cardiac catheterization either.
CATHY: No, it's not, and the presence of those symptoms helps you identify what's going on. So, acute interstitial nephritis, which is Option A, is generally caused by a drug reaction and would also cause eosinophilia and renal failure, like we see in this case. But we didn't hear about any new medications that this patient was taking, so I have no reason to really think that this is the cause of his renal failure now.
CHARLIE: Okay, so Option A, acute interstitial nephritis, is also incorrect. What do you think of the other options?
CATHY: Option C talks about Churg-Strauss syndrome, which is now also called eosinophilic granulomatosis with polyangiitis. It's a small-to-medium vessel vasculitis that does present with renal dysfunction and eosinophilia. But lung involvement is the most common, so you'll hear about patients with asthma and allergic rhinitis most commonly. There are skin findings that can occur, but typically, that's cutaneous purpura, not the livedo reticularis that you hear about in this case.
CATHY: Also, it usually happens much earlier in life, so it would be very atypical for it to present for the first time in a 75-year-old man.
CHARLIE: Okay, so now you've ruled out Churg-Strauss syndrome, and we're down to atheroembolic disease and the hypereosinophilic syndrome. Which do you think is going on here? The patient's clinical scenario is most consistent with atheroembolic renal disease. So, atheroemboli in the kidney are strongly associated with aortic aneurysmal disease and renal artery stenosis. Now, most clinical cases can be linked to precipitating events, such as angiography, like we heard about in this case, but also vascular surgery, anticoagulation with heparin, thrombolytic therapy, or even trauma.
CHARLIE: Clinical manifestations of this syndrome commonly develop between right after whatever the inciting event is, or up to two weeks after the inciting event, so the time course would fit with that.
CHARLIE: So, the time course in this case fits, and we're also told that he had diffuse atherosclerosis found in his angiography, although he had no intervenable coronary lesions.
CATHY: Seven days post-procedure is typical, and it may continue to develop for weeks thereafter. Systemic embolic disease manifestations, such as fever, abdominal pain, weight loss, are not that common and are present in less than half of patients, although cutaneous manifestations, like livedo reticularis or even sometimes localized toe gangrene may be more common. Worsening hypertension and deteriorating kidney function are also common.
CATHY: Now, the lab findings that we would expect include a rising creatinine-- we see that here; transient eosinophilia, that happens in more than half of cases-- we also see that here; and elevated ESR and hypocomplementemia is a little less common. But we see most of those findings in this case, which leads me to believe that that's the cause of what's going on here.
CHARLIE: Okay, so the answer to this question is C. atheroembolic disease. And interesting that the question noted that the access point for this case was the right femoral artery, and interventional cardiologists, utilizing technological advancements, have allowed them to utilize less dangerous arteries, such as the brachial or radial arteries, for diagnostic cardiac catheterization.
CATHY: Yes, the combination of the host factors, recent procedure, and exam and laboratory findings make this the most likely cause.
CHARLIE: Okay, let's round it out, and tell me why you don't think this is the hypereosinophilic syndrome.
CATHY: So, that's a subcategory of idiopathic eosinophilia with a persistent increase of the absolute eosinophilic count to over 1500 eosinophils/mcL. But you also need to have the presence of eosinophil-mediated organ damage. So, this could include cardiomyopathies, gastroenteritis, cutaneous lesions, sinusitis, pneumonitis, neuritis, and even vasculitis. In addition, some patients will manifest with thromboembolic complications or even hepatosplenomegaly, and then you either get elevations or decreases in the rest of the blood counts too.
CATHY: In this case, you'd have to decide first if the eosinophilia is not due to a different cause-- which, I said before, I think it is-- and, again, it'd be very uncommon to present for the first time in someone of this age who has another more likely cause of his eosinophilia.
CHARLIE: Great. So, the teaching point in this case is that atheroembolic renal disease commonly occurs after some precipitating event, and commonly presents with skin findings, rising creatinine, and a transient eosinophilia, although there can be worse systemic symptoms, like fever, abdominal pain, and weight loss.
CATHY: And if you'd like to read more about this, you can check out Harrison's chapter on Disorders of the Cardiovascular System. ♪ (music) ♪