Friday, December 12, 2008

Interesting Case! (2)

Saw this patient in ER. Think it's interesting to share.

A 84 year-old man was pushed in for progressively worsening dyspnea. According to his daughter, he only has history of gastritis. The dyspnea has been there for 1 week, but he denies any chest pain. There is history of reduced effort tolerance but not much of orthopnea or any ankle swelling. Upon further questioning, the daughter told that he has been feeling lethargic and having poor appetite for the past 2 months.

On examination, he looks mildly tachypneic with SPO2 94% on room air. Lungs were generalized crepitations on auscultation. Abdomen has a spleen palpable with shifting dullness positive. No pedal edema. Multiple cervical and axillary painless lymph nodes palpable.

Then the daughter showed some blood results that he just took in a private lab few days ago.
Hemoglobin: 8.4 g/dL
Total protein: 118 g/L
Albumin: 19 g/L
ALT: 40 IU/L
ALP: 120 IU/L
Se Calcium: 2.4 mmol/L (2.1-2.6)
Se Mg: 0.8
BUSE - within normal limits

ECG shows ST depression over I, aVL, V4 to V6.
Trop T stat: Negative

Your colleague thinks that he should be treated as Acute Coronary Syndrome with left ventricular failure, based on the ECG and chest findings.

Do you agree? And if not, why?

(Answer's in comment)

Related post:
Interesting case! (1)


Darren Lee said...

The answer is no.
Despite the ECG findings, he's less likely to have ACS in view of no chest pain, and not much of risk factors other than age/gender. And for the lungs with generalized crept, a lower SPO2 is expected and pt'll be in bad SOB.

He has something else.
The constitutional symptoms(LOA, lethargy), anemia, splenomegaly and ascites point to possible malignancy.
The liver function test showed abnormally high protein with low albumin, with corrected calcium of 2.82, plus multiple lymph nodes, what do you think?

So the diagnosis should be:
1. Lymphoproliferative disorder with lung infiltration;
2. Hyperglobulinemia TRO multiple myeloma/ Waldenstrom's macroglobulinemia

Hence, the ECG is likely to be due to hyperviscosity caused by paraproteinemia, and lungs crepts are due to the infiltration.

So if you treat as heart failure and give diuretics, it's going to worsen the hyperviscosity and hypercalcemia!

Such a big trap isn't it?

Zzzyun said...

yeah, imho, doesnt hv much to support for ACS.. there was no pedal edema to support heart failure (it is pretty common rite?)

while the rest of the other symptoms seemed to point to another direction.

but i could only guess it was some lymphoproliferative disorder due to the splenomegaly and lymphadenopathy la. the rest i didnt think of it ade.. o.O

but the part abt giving diuretics wic will only worsen it is scary!

so hows the old man now?

Jason said...

Good case Darren,

If its not HF, what i think of is lymphoma -painless cervical lymphnodes, spenomegaly.

dint think bout multiple myeloma without bone pain....

scary, if patient given wrong treatment.
Need to study more....

confessions of a medical student said...

sometimes patients don't have the typical chest pain, and only complain of chest discomfort.. plus ECG findings supportive of ACS somemore... mamangpun trap... furthermore, how many people has LFT done at presentation...

p/s: albumin:globulin ratio = 1:5 !! WOW!! plus, with anemia and spleenomegaly, despite normal calcium... could be multiple myeloma..

Darren Lee said...

zzzyun: The old man is fine now..still in ward. Awaiting result of protein electrophoresis...

Jason: Ya lymphoma is one of the differentials too. Also need to be excluded.

shinyin: Ya it's kinda lucky that LFT was there. And the "normal" calcium is a trap..coz if we calculate the corrected Ca, it's actually high!

Sze Kie said...

Should consider haematological disorders.Review platelet and white cell count as well.

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