Cases from the Wards

Maryland ACP 2015

Disclosures- None
20 year-old with Buttock Pain and Fever

Case 1
 Case Study of A.H.
• 20 yo white female with no significant pmhx
• 3 weeks before presentation, AH noted fever, non-
bloody diarrhea, & abdominal pain that resolved in
48 hrs
• 2 weeks prior to presentation, noted right hip pain
that radiated down the back of her right leg.
Intermittent fevers
– Treated with doxycycline and NSAIDs
• Pain worsened, and she was unable to walk
 Case Study of A.H.
• MRI of hips/bone scan performed 10 days
prior to presentation were read as normal
• No recent trauma- Fallen off her horse and on
her buttock multiple times in the past
 Case Study
• At time of presentation
– Unable to walk
– Slept only on her left side in a recliner
– Unable to fully extend the right hip
– No recent fever
• Nl fmhx, social hx, developmental hx, and
pmhx. Denied sexual activity
 Case Study: PE
• Nl vitals
• Very uncomfortable- 10/10 pain score
• Exam normal but for MSK exam
– Tenderness over the right SI joint
– Tenderness in right groin and upper thigh
– Very limited active right hip flexion with limited
internal/external rotation
– Position of comfort was hip flexion with external rotation
– No signs of enthesitis
What additional labs/diagnostics do
you want?
 Who would you consult?
• Oncology
• Infectious Disease
• Rheumatology
• Ortho
• No one- I got this!
 Case Study: Labs
• Normal CBC except Hemoglobin- 10.8 g/dL
• Normal CMP, CK, and Aldolase
• Rheumatoid factor and Lyme disease serology- negative
• HLA-B27 by flow was not present
• Serum C3, C4 and complement function- normal
• Antinuclear antibody was positive with a 1:80 titer
• No GC with multiple swabs
• Cultures of blood were negative

• Erythrocyte sedimentation rate- 102 mm/h

• C-reactive protein- 6.4 mg/dL
 Case Study: Radiology
• Review of outside films
– Plain film: revealed evidence of widening of right
SI joint with irregularity and sclerosis on the iliac
side
– Bone scan: subtle inc uptake in right SI joint
– MRI: abnl signal in right SI joint and adjacent
sacrum and iliac. Minimal fluid
 Diagnostic Procedures
• Culture of stool
• CT guided aspiration of right SI joint with
culture
– Gram stain negative from SI joint aspiration
 Helpful Results
• Stool and SI joint fluid grew Salmonella
enterica serotype Montevideo that was pan-
sensitive
 The Big Finish
• AH later remembers that the day before her
GE illness, she had baked cookies for her
mother’s birthday with eggs from their farm
and ……………………
• …………… she ate lots of batter!!!!!!!!!!!
 Final Diagnosis:
• Salmonella gastroenteritis with hematogenous
spread resulting in Salmonella septic sacroilitis
Reacquaint Ourselves with the SI
Joint
•Joint formed between the auricular surfaces of the sacrum
and the ilium
•The articular surface of each bone is covered with a thin
plate of cartilage in close contact with each other
 Sacroiliac Articulation
(articulatio sacroiliaca)
 Inferior two-thirds: separated by a space containing
a synovial fluid permitting free motion
 Greatest at birth
 Decreases from birth to puberty
 In women, mobility increases after puberty to peak
around age 25
 During pregnancy, relaxin effects on ligaments increases
mobility
 Mobility decreases in the 4th and 5th decades and is
absent in the elderly
 Vascularization of the SI Joint
• Peaks in 2nd decade of life and declines after
the age of 30
• Originates from the pelvic and paravertebral
venous plexus of Batson
 Age Distribution in Decades
Salmonella septic sacroilitis
24
22 Median Age- 16
20 years old
18
Mean Age- 18.8
16
years old
14
12 Cases
10
8
6
4
2
0
0-10 11-20 21-30 31-40 41-50 51-60 > 60
 Age Distribution of Pyogenic SI
• Mean age- 22 years, range 1-71 years1
– 166 cases of confirmed pyogenic SI joint infections in
children and adults from 1878-1990 (excluded
mycobacteria and brucella)
• Mean age: 20 years2
– 177 cases from 1990-1996 in the literature

– 1Vyskocil
JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint.
Case reports and review of the literature. Medicine (Baltimore). May 1991;70(3):188-197.
– 2Zimmermann B, 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin Arthritis Rheum. Dec
1996;26(3):592-604.
Symptoms of Salmonella septic sacroilitis
100
90
80
70
60
50
40
30
20
10
0
Buttock Pain Recent Gait Unilateral Fever
Disorder Pain
Risk Factors for Salmonella septic sacroilitis
24
22
20
18
16
14
12
10
8
6
4
2
0
Recalled GI Egg Nog Trauma Immuno-
Illness Ingestion compromised
 Lack of Risk Factors other than Age
• No IVDU
• No Sickle Cell Disease
• No Corticosteroid Treatment
• No SLE
• No GU infections
 Delay in Diagnosis of Pyogenic SI
• Lack of awareness of the entity
• Nonspecific presentation of the illness
• Posteriorly situated physical findings
• Referred pain makes other more common
diagnoses seem more likely
– Appendicitis
– Septic Hip
– Lumbar Disc disease

•Gordon G, Kabins SA. Pyogenic sacroiliitis. Am J Med. Jul 1980;69(1):50-56.

 SI Joint Afflictions
• Septic Arthritis
• Inflammatory disorders like
the seronegative
spondyloarthropathies
• Crystal arthropathies- gout,
pseudogout
• Rheumatoid arthritis
• Familial Mediterranean
Fever
• Hyperparathyroidism
• Behcet’s disease
• Relapsing polychondritis
• Whipple’s disease
• Trauma
• Metastatic lesions or
sarcoma
• Degenerative lesions
• Osteitis condensans ilii
• Radiation therapy
• Immobilization
• Sarcoid?
 Delay in treatment of Salmonella SI
• > 80% Gram-positives
– Staph Aureus by far most common at 70%
– 2nd most common- Streptococcal species
• 9 % of all cases
• 21% of strep cases associated w/ gyn conditions
• 6 caused by GBS
• 17% Gram-negative infections
– Pseudomonas most common- only IVDUs
– E. coli- 8 cases
• Almost always associated with UTIs
•Zimmermann B 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin Arthritis Rheum.
1996;26:592– 604.
89-year-old with decreased elimination

Case 2
 Case Study 2
• An 89-year-old woman with untreated stage 0 CLL and a
history of stage III colorectal cancer
– treated with hemicolectomy and adjuvant capecitabine 3 years
prior
• Reported feeling “dehydrated,” nauseated, and
constipated, with decreased output from her colostomy.
• No urine output for 4 days
– felt that she had to urinate, “but I can’t.”
• Decrease in fluid intake.
• Denied fevers, chills, abdominal pain, or loss of appetite.
• While waiting to be seen in the emergency department, the
patient was finally able to urinate.
 PMH
• Colon cancer with no evidence of recurrence
– Normal postoperative PET three years prior
– Normal colonoscopy one year prior
– Normal surveillance CT one year prior
• Other history
– Well controlled hypertension
– Well controlled hypothyroidism
– Well controlled hyperlipidemia
– Chemotherapy-induced neuropathy
– Anxiety
 Medications
• buspirone 5 mg 3 times a day
• metoprolol 25 mg twice a day
• lisinopril/hydrochlorathiazide 20/25 twice daily
• pantoprazole 40 mg once daily
• levothyroxine 100 mcg once daily
• gabapentin 300 mg twice a day
• solifenacin 5 mg once daily (started 10 days prior
to her admission) for bladder overactivity
• fenofibrate 145 mg nightly
 Physical Exam
• Appeared non-toxic
• Abdomen:
• hypoactive bowel sounds and mild diffuse
abdominal tenderness
• No peritoneal signs

• Foley placed with PVR of 50cc

 2 months admission
before

Sodium (mEq/L) 143 137

Potassium (mEq/L) 4.5 5.2

Chloride (mEq/L) 102 99

CO2 (mEq/L) 27 22

BUN (mg/dL) 18 90

Creatinine (mg/dL) 0.8 3.4

WBC Count/cu mm 19740 28720

TSH (uIU/mL) 1.76 1.64

Small Bowel Obstruction
What is causing her SBO?
Do you send her to surgery?
 Hospital Course
 With cessation of solifenacin and
lisinopril/HCTZ and hydration, her
constipation, acute renal failure, and feeling of
urinary retention resolved
 After 4 days, she tolerated a diet, and her
colostomy output normalized
 After eight months, her creatinine and
abdominal CT were normal
 2 months admission 3 months after
before

Sodium (mEq/L) 143 137 143

Potassium (mEq/L) 4.5 5.2 3.9

Chloride (mEq/L) 102 99 106

CO2 (mEq/L) 27 22 28

BUN (mg/dL) 18 90 18

Creatinine (mg/dL) 0.8 3.4 0.9

WBC Count/cu mm 19740 28720 17750

TSH (uIU/mL) 1.76 1.64

 Final Diagnosis
• Small bowel pseudo-obstruction and the
feeling of urinary retention associated with
solifenacin, an antimuscarinic
 Safety Analysis of Solifenacin
Randomized Placebo Controlled Double-Blinded Studies
Constipation
Number of Patients in Number of patients Micturition/24 hours
Safety Analysis (percentage)

Mean Decrease from

placebo 5mg 10mg placebo 5mg 10mg Baseline Baseline

placebo 5mg 10mg

Chapple6*^† 267 279 268 5 (1.9) 20 (7.2) 21 (7.8) 12.08 - 12.32 1.2 2.19 2.61

Cardozo5*^† 301 299 307 6 (2.0) 11 (3.7) 28 (9.1) 12.05 - 12.31 1.59 2.37 2.81

Wagg4• 422 192 431 18 (4.3) 18 (9.4) 78 (18.1) 11.6 - 11.7 1.1 2.0 2.5

*Trials were 12 weeks and did not utilize an intention to treat analysis
^ Inclusion criteria: men and women aged ≥ 18 years, symptoms of overactive bladder syndrome for ≥ 3 months, average frequency of ≥ 8 voids/24h
† Exclusion criteria included significant bladder outlet obstruction, postvoid residual > 200mL, presence of a neurological cause for detrusor muscle
overactivity, any medical condition contraindicating the use of antimuscarinic medication, diabetic neuropathy, and use of any drugs with cholinergic or
anticholinergic side-effects
• Pooled analysis of patients ≥ 65 years old in Chapple6, Cardozo5, and 2 unpublishedstudies2
 Int Urogynecol J (2012) 23:983–991
urgency episodes/24 hours

micturitions/24 h

urge incontinence episodes/24 h

 Discussion
• Prior to 2008, in 4 randomized trials, only 189 patients of the 1811 who
received active drug were > 75 years.
• In the four 12-week clinical trials in which 1158 patients were treated with
solifenacin 10mg, there were 3 serious intestinal adverse events: fecal
impaction, colonic obstruction, and intestinal obstruction.
• Patients receiving solifenacin were more likely to experience constipation
than those given placebo
• 5mg- 5.4%
• 10mg- 13.4%
• Placebo- 2.9%
• In patients who urinated an average of 11.6-12.32 times per 24 hours,
efficacy trials showed a mean decrease from baseline of 1.1-1.59 times
with placebo as compared to 2.0-2.81 times with solifenacin.
 Conclusion
• First think drugs
• Solifenacin’s risks likely outweigh its benefits
– Dearth of clinical data on patients > 75 years of age
– Effects of age on the pharmacokinetics
– Higher likelihood of bowel pathology in the elderly
– Increased risk of solifenacin induced side effects in the
pooled analysis of patients ≥ 65 years old
– Minor clinical benefit of solifenacin
55-year-old with right epigastric pain

Case 3
 April 30- Urgent Care
• CC: Right epigastric pain in a 55-year-old
• HPI
– Lung pain under right breast
• Pain improved with rest and sitting up. Almost gone @ rest
• Worse with cough
• Hurts with deep breathing.
• Began 4/19. Left ureteral stent placed on 4/9
– Noted DOE with walking up a flight of stairs
• 4/19-4/23, then resolved
• Started again 4/28

December 30, 2018 47

 Case Presentation
• 55 year old
• Pmhx:
– 390 lbs, 6’1’’ BMI: 53
– Cystinuria
– HTN
• Past Surgical Hx
– Recent lithotripsy
– Left ureteral stent for obstruction by stones (4/9)
– Multiple percutaneous nephrostomy procedures x 10yrs
• Medications
– Ace-I

December 30, 2018 48

 Physical Exam
• VS
– 155/97, p-122, Temp- 99.1, Sat-92%
• Nothing else obvious on exam
Labs from 3/24 Labs from 4/30
• Na- 136
• Na- 141
• K- 5.4
• K- 4.7
• Cl- 104
• Cl- 103
• CO2- 24
• CO2- 30
• BUN- 45
• BUN- 17
• Cr- 5.1
• Cr- 1.4
• Gluc- 97
• Gluc- 97
• Nl LFTs
• WBC- 9.3
• WBC- 12.5
• HCT- 47
• HCT- 44.5
• Plts- 193
• Plts- 166

50
 EKG from 3/29

December 30, 2018 51

 V/Q from 4/30

December 30, 2018 52

 CT of abd from 4/30
no contrast
• Left sided double-J stent in satisfactory
position
• Moderate left hydronephrosis
• Bilateral renal stones
• Hiatal hernia
• Small pericardial effusion
• Gallstones
What do you think is going on?
1. A
2. B
3. C

A B C D
 May 1
• US guided left perc nephrostomy tube
• Left ureteral stent is occluded as is the distal
left ureter on nephrostogram

December 30, 2018 55

 5/7
• Sees urologist, but can’t get to the clinic
– Too SOB in the parking
• Direct admission with gen med and renal
consults

December 30, 2018 56

 Gen Med Consult
• DOE has worsened but SOB is not present while
sitting
• DOE with brushing teeth and dressing
• No CP, palpitations, lightheadedness, or dizziness
• Good urine output
• Anorexia recently with 20 lb weight loss
• No fevers, chills, sweats, rashes, arthraligias, or
myalgias
• Cause of breathlessness remains a mystery
• Orders echo and stress test
December 30, 2018 57
 Labs from 5/7

• Na- 141 • WBC- 14

• K- 4.3 • HCT- 46.8
• Cl- 105 • Plts- 215
• CO2- 27
• BUN- 23
• Cr- 1.8
• Nl LFTs
58
 CXR

December 30, 2018 59

 EKG from 5/7

December 30, 2018 60

What do you think is going on?
1. A
2. B
3. C

A B C D
 Echo from 5/7

December 30, 2018 62

 Pre-Test Probability
• Gestalt (experience)
– History of Present Illness
– Risk Factors
– Physical exam
• Clinical Prediction Models

December 30, 2018 63

 Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging:
management of patients with suspected pulmonary embolism presenting to the emergency department by using a
simple clinical model and d-dimer. Ann Intern Med. Jul 17 2001;135(2):98-107.
December 30, 2018 64
 10% 30% 70%

low intermediate high

Jaeschke R, Guyatt GH, Sackett DL. Users' guides to the medical literature. III. How to use an article
about a diagnostic test. B. What are the results and will they help me in caring for my patients? The
Evidence-Based Medicine Working Group. Jama. Mar 2 1994;271(9):703-707.
December 30, 2018 65
 Likelihood Ratios
• Derived from sensitivity and specificity
• It is a multiplication factor
• (Pre-test odds)(LR)= post-test odds
• We convert odds to percentages or use the
Bayes’ Nomogram

December 30, 2018 66

 When are Likelihood Ratios
Helpful?
• LRs >10 or < 0.1
– generate large, and often conclusive changes from pre- to post-test
probability
• LRs of 5-10 and 0.1-0.2
– generate moderate shifts in pre- to post-test probability
• LRs of 2-5 and 0.5-0.2
– generate small (but sometimes important) changes in probability
• LRs of 1-2 and 0.5-1
– alter probability to a small (and rarely important) degree.
• How helpful also depends on your pre-test probability

December 30, 2018 67

December 30, 2018 68
 46%

13%

December 30, 2018 69

 Conclusion
• Make sure you know the operating
characteristics of the test before deciding on
the post-test probability
• Always think about the pre-test probability
• Combine that with whether the diagnosis is
“high stakes” to decide what needs to happen
to lower the post-test probability to an
appropriate level