Internal Medicine: Over 200 Case Studies

Key

Allergy

Case 1

A 70 year old retired executive presents to the ER on an August day after having over 8 wasp stings while out in his back yard. Shortly after the stings, he became lightheaded, SOB, with facial swelling. In the ER, he is found to be in anaphylactic shock, and is admitted to the ICU.

Yellow Jackets are very aggressive stingers

The most aggressive stinging insects are vespid wasps but other hymenoptera such as honey and bumblebees will obviously sting also. Apitoxin is the venom. It contains mellitin, apamin, adolapin, phospholipase, hyaluronidase, histamine, dopamine, and proteases. 1% of the population is severely allergic to beestings. Treatment of anaphylactic shock- epinephrine (adrenaline; a catecholamine) IM/SQ, .5 mg 1:1000), may repeat in 5 minutes. High volume fluids, O2, IV steroids, and antihistamines (H1 and H2 blockers).

Differential diagnosis of SHOCK: Anaphylactic, Septic, Cardiogenic, Endocrine (Addisonian Crisis), Cerebral, Hypovolemic.

Causes of anaphylaxis- Idiopathic- 40%. Others: Foods- in kids, peanuts. Bee stings in adults. Insect bites- fire ants. Semen. Latex. Monosodium glutamate. Food colors. Topical meds. Exercise. Neuromuscular blockers. Antibiotics. Extreme cold/hot.

Case 2

A 40 year old cardboard box salesman presents to your office with an increase in post nasal drip, watery eyes, and what seems like constant sneezing since the start of hayfever season. You diagnose seasonal allergic rhinitis.

Up to 25% of people are affected by Allergic Rhinitis. Occurs after 6 years of age. Cross-reactivity occurs- i.e. birch pollen with apples/potato skin. The visible wind-blown pollens are the cause of AR, not the insect-pollinated plants. (too heavy to float). Plants responsible for hayfever: pine/birch/olive trees, grasses (rye), weeds, (ragweed-Ambrosia, mugwort-Artemisia) and golden rod (Solidago).

Managing Allergic Rhinitis- avoid the allergen! Intranasal steroids- beclometh- asone (Vancenase), triamcinolone (Nasacort), budesonide (Rhinocort), fluticasone (Flonase), mometasone (Nasonex), ciclesonide (Zetonna, Omnaris), azelastine/ fluticasone (Dymista). Antihistamines- H1 antagonists- 1st generation- cross BBB and cause drowsiness, anticholinergic side effects- diphenhydramine (Benadryl), cyproheptadine (Periactin), Azelastine (Astelin) nasal spray/eye drops. 2nd generation- don’t cross BBB- cetirizine (Zyrtec), loratadine (Claritin), astemizole/terfenadine (Hismanal/Seldane; dropped by FDA for fatal reactions), 3rd generation- levocetirizine (Xyzol-very potent, 5 mg tab), desloratadine (Clarinex), and fexofenadine (Allegra). Olopatadine (Patanase) drops/eyes and spray/nasal. Topical decongestants- pseudoephidrine or oxymetazoline (Afrin), etc. eyes/nasal. Cromolyn- mast cell stabilizer- Nasalcrom or Intal inhaler. Leukotriene receptor antagonist- montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo), can be very helpful.

Case 3

A 65 year old retired cement finisher presents with an itchy, raised rash (urticarial with welts) all over his body. One week ago, he was placed on Amaryl (glimiperide). You diagnosis a sulfa allergy.

Raised lesions of urticarial

Urticaria- Causes: Drug reactions- insulin, vaccines, meds (aspirin, beta-lactams, sulfa (glimiperide contains sulfa), anticonvulsants, ibuprofen, clotrimazole). Food additives (MSG), food (shellfish, nuts, scombroid)). Transfusions. Infections- i.e. rhinovirus, viral exanthems. Bites/Stings. Collagen Vascular- SLE. Vasculitis- serum sickness. Physical triggers- heat (exercise), cold, sunlight, pressure. Chronic-idiopathic, stress? Treatment- 2nd and 3rd generation H1 blockers. Avoidance of allergen. Also can use doxepin, and steroids for flare-ups.

Types of allergens- an allergen is an antigen capable of stimulating a Type-1 hypersensitivity reaction in atopic individuals through IgE responses. A hereditary predisposition is called atopy. Common allergens- Animal products- fel d 1 protein in cat saliva, dog/cat dander, cockroach, dust mite excreta, wool. Drugs- penicillin, salicylates, sulfa. Foods- celery, corn, egg whites, pumpkin, legumes- peanuts (peas, soybeans) milk, seafood, sesame, tree nuts-pecans/almonds, wheat, banana, pineapple, avocado, kiwi, strawberry, shellfish- shrimp, oysters. Insect stings- bee/wasp venom, mosquito bites. Mold spores- airborn basidiospores such as mushrooms, rusts, puffballs, aspergillus. Latex- Type 1 anaphylaxis and Type 4 allergic dermatitis. Metal- nickel. Plant pollens- rye grass, weeds such as ragweed, trees like birch, willow, poplar, pine.

Hypersensivity Reactions-Type 1- allergic, anaphylaxis, atopy. Mediated by IgE, IgG4. Type 2- cytoxic, antibody dependent - Grave’s, Hemolytic anemia. Goodpasture’s, Myasthenia gravis. Mediated by IgM or IgG and complement. Type 3- immune IgG-IgM complexes and complement- serum sickness, Arthus reaction, SLE, RA, Stevens-Johnson Syndrome, hypersensitivity pneumonitis. Type 4- delayed hypersensitivity, cell-mediated immunity. Contact dermatitis, MS, transplant rejection. Mediated by T-cells.

Case 4

A 34 year old teacher with a history of seasonal allergic rhinitis presents to your office with recurrent sinus infections for the last several years, flare-ups of asthmatic bronchitis, and recurrent bladder infections. Could she have an immunoglobulin deficiency?

Dysgammaglobulinemia- IgA deficiency- most common inherited immunoglobulin deficiency. 1/333 people. Recurrent infections of mouth, airways, and digestive tract, GU tract. Associated with autoimmune diseases. No specific Rx. Most are asymptomatic. IgG deficiency- four subtypes, not common. IgG4 deficiency is associated with autoimmune pancreatitis. IgM deficiency- 1/3000 population. Associated with increased frequency of URIs, asthma, allergic rhinitis.

Questions:

1.   True or False. Mast cells have receptors for IgE, which trigger the release of histamines through the contact of allergens.

2.   What is responsible for ragweed allergy? These include:

a)   pine/birch/olive trees

b)   Rye grass

c)   Weeds

d)   Ambrosia

e)   Golden Rod

f)   All of the above

3.   The following are helpful in treating allergic rhinitis:

a)   Intranasal steroid

b)   H2 antagonists

c)   Topical decongestants like Afrin

d)   Leukotriene receptor antagonists like montelukast

e)   Avoidance of trigger

f)   a,c,d,e

g)   All of the above

4.   Anaphylaxis can be associated with all the below symptoms:

a.   Diarrhea

b.   Hives

c.   Headache and confusion

d.   Flushing

e.   SOB

f.   B,C,D,E

g.   All of the above

5.   What percent of the population is allergic to beestings?

a)   1%

b)   5%

c)   6%

d)   10%

6.   What % of anaphylaxis causes is idiopathic?

a)   40%

b)   10%

c)   60%

d)   5%

7.   The following is associated with urticarial (hives):

a)   Insulin

b)   MSG

c)   SLE

d)   Heat

e)   Physical pressure

f)   All of the above

g)   a,b,d,e

8.   A transplant rejection is considered what type of hypersensitivity reaction?

a)   Type 1

b)   Type 2

c)   Type 3

d)   Type 4

9.   Which metal found in earrings causes allergic reactions?

a)   Nickel

b)   Cadmium

c)   Silver

d)   Gold

e)   Bronze

f)   Aluminum

10.   What is the most common inherited immunodeficiency?

a)   IgG

b)   IgM

c)   IgE

d)   IgA

e)   IgD

Cardiology

Case 5

An 80 year old retired factory worker presents to the ER with one week of increasing SOB associated with PND and orthopnea. He has noted a weight gain from 180 to 190 pounds during. He has a history of CABG-4 vessels and continues to smoke ½ pack of cigarettes daily. You suspect CHF.

Sytolic Heart Failure-most common cause of left sided heart failure is CAD and aging, alcohol, aortic stenosis, noncompliance with meds. ACE inhibitors, carvedilol/metoprolol (tartrate-immediate release, succinate is long-acting release), and diuretics are DOC. AICD (Automatic implantable Cardioverter Defibrillator) in patients with NY Class 2-3, EF 35% or less. CHF is the leading cause of hospitalization in patients older than 65 years. 2 gram Na restriction, 50 ounce/day fluid restriction is key for compliance. New York Heart Association (NYHA) is a functional classification system. Class I- mild, no limitation of activity. No SOB with ordinary activity. Class II- mild, slight limitation of activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or SOB. Class III- moderate, marked limitation of activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitations, and SOB. Class IV- severe, unable to carry out any physical activity without discomfort. Symptoms are at rest also. Discomfort increased with activity.

Case 6

A 75 year old female retired RN presents to the office with intermittent lightheadedness, fatigue, feeling faint, SOB, and increasing leg swelling over the last 4 weeks. She has a history of a grade 3/6 heart murmur at the second right intercostal space. You suspect aortic stenosis.

Aortic Stenosis- 25% of adults > 65 y/o have it. Common symptoms- syncope, CP and CHF (Aortic Stenosis triad) Can be silent. The heart murmur- 2nd right intercostal space, radiates to carotids- Gallavardin’s phenomenon. Watch for LVH, and angina pectoris flare ups. Valve area normally 1.5-2.0 square cms. < 0.8 square cms is considered severe AS. Pathology in most patients is bifid valve or aortic sclerosis (calcified in elderly).Treatment is AV replacement or balloon valvuloplasty. No need for prophylaxis since AHA guidelines changed in 2007, unless known congenital bifid valve.

Case 7

A 58 year old female office worker presents to you with a history of SOB that has been increasing over the last 6 weeks. She notes lightheadedness and palpitations. At times, her pulse is irregular and fast. An EKG shows:

6 Second Strip= 30 boxes, then X 10= Rate= 180

Atrial Fibrillation- most common cardiac arrhythmia. Quality of life tends to be poorer without control. (lose atrial kick) 8% in people over 80 years old have it.

Causes- HTN, heart disease (CAD or valvular), chronic lung disease, hyper-thyroidism, alcohol abuse are the most common.Treatment- 1) anticoagulation with either warfarin or Pradaxa (dabigatran), a direct thrombin inhibitor. Rivaroxaban (Xarelto), a Factor 10a inhibitor, and Apixaban (Eliquis) is available. Pradaxa and Xarelto-approved for non-valvular disease. 2) Rate control-metoprolol, diltiazem. Infrequently digoxin. 3) Rhythm control-chemically with amiodarone (Pacerone)/ or dronedarone (Multaq), dofetilide (Tikosyn), or Direct Current Conversion. Ablation is used for cases that aren’t controlled.

Case 8

A 70 year old male, former CEO, presents to the office complaining of intermittent lightheadedness (almost fainting) and a slow pulse into the mid to high 30s at times while vacationing in for 3 weeks in the Netherlands. Many days he was asymptomatic. He takes enalapril for high blood pressure. A rhythm strip shows the following and you diagnose third degree heart block:

Third degree heart block- patients present with significant bradycardia and sometimes hypotension. Causes are cardiac ischemia; especially inferior wall MI, Lyme’s, idiopathic. Treatment is a dual chamber pacemaker. Atropine may be given if hypotensive, but usually has short term effect only.

Case 9

A 55 year old plumber presents to the ER with black outs. He is usually out for about 10 seconds and then comes to. No seizures have been witnessed. He has had 3 of these episodes over the last 8 weeks. The last time it occurred, he was urinating in the bathroom, and his wife heard a thump when he fell. He remembers periodically fainting as a boy growing up.

Loss of Consciousness- the majority of LOC is benign and related to vasovagal (vasodepressive, neurocardiogenic) syncope. Rx- anticholinergics like hyoscy- amine 0.125 mg bid, scopolamine, SSRIs, metoprolol. Orthostatic syncope may be treated with fludrocortisone (Florinef 0.1 mg/day), or midodrine (Proamatine 5-10 mg tid). Most syncope will be diagnosed in the ER. 40% of cases admitted to the hospital will not be solved.

Case 10

A 49 year old obese civil engineer with a history of smoking 1-2 packs of cigarettes a day comes to the ER after experiencing a squeezing tightness around his chest. It feels like an elephant is sitting on my chest. He has nausea and sweating. He has never had heart problems before. In the ER, his initial blood pressure is 180/100. You suspect accelerated angina or a Myocardial Infarction.

Location of STEMI- II, III, AVF- inferior (especially smokers)= right coronary artery disease. Anterior septal- V1-V2, anterior-lateral- I, AVL, V3-V6.-LAD/circumflex artery disease. (widowmaker’s disease). Immediate treatments include oxygen and nitroglycerin. Most cases are treated with thrombolysis (Plavix-clopidogrel or Effient-prasugrel or Brilinta -ticagrelor, heparin or LMWH, and aspirin), and PCI (percutaneous coronary intervention)- bare-metal stents or drug-eluding stents are primarliy used. Other meds used are the glycoprotein IIb/IIIa inhibitors-block platelet and thrombin interaction (abciximab-Reopro or eptifibatide-Integrilin), and now bivalirudin (Angiomax), a direct thrombin inhibitor, similar to hirudin, the chemical in leech saliva. Five types of MI: Type 1- spontaneous MI secondary to plaque rupture Type 2- MI secondary to increased oxygen demand Type 3- acute MI associated with sudden death Type 4- MI associated with percutaneous angioplasty or stents Type 5- MI associated with CABG. Scoring of MI for mortality in first 14 days- TIMI (Thrombosis in MI)- Mnemonic = AMERICA (7 Points)- Age>65, Markers- increased, EKG- ST segment changes. Risk factors- 3 or more risk factors- age, family history, diabetes, high cholesterol, HTN, smoking, obesity, sedentary lifestyle, metabolic syndrome. Ischemia- 2 or more anginal events in last 24 hours. CAD- prior 50% coronary stenosis. Aspirin use in last week. Point Score- 0-1- 4.7%, 2- 8.3%, 3- 13.2%, 4- 19.9%, 5-26.2%, 6-7- 40.9%. Cardiac Biomarkers- Troponin- the most sensitive/specific test for myocardial injury. Better than CPK-MB. Peaks at 12 hours. Released in 2-4 hrs after infarct and stays up for 7 days. Can be elevated in infarct, PE, CHF, and myocarditis. Other markers are LDH-1, AST, myoglobin, BNP, IMA (Ischemia Modified Protein), and GPBB (glycogen phosphorylase B)

Cardiac stents-Types of stents: Bare-metal stents (stainless steel). Drug- eluding stents (Taxus-tacrolimus). Biodegradable stents. Radioactive stents. Bioactive stents.

Case 11

An 19 year old slender waitress with history of mitral valve prolapse presents to the emergency room with a fast pulse and lightheadedness over the last 3 hours. In the ER, she has a pulse of 160 and a blood pressure of 130/80. You suspect SVT.

Supraventricular Tachycardia- not life threatening. At least 5 types; including multifocal atrial tachycardia seen in in severe COPD patients, atrial flutter, and JET (Junctional Ectopic Tachy). Physical maneuvers that stimulate vagus nerve/ AV block don’t always work. Adenosine 6 mg IV is an ultra-short acting AV node blocker. If it works, then suppress future SVT with diltiazem, verapamil, or metoprolol. Radioablation surgery has revolutionized treatment for resistant SVT. Signal average EKGs (SAEKGs) can be helpful to stratisfy risk for sudden death from a ventricular arrhythmia (PVCs or Vtach)

Case 12

A 70 year old Black retired Marine colonel presents to the local emergency room with 4 weeks of intermittent lightheadedness, recurrent nose bleeds, dizziness, and headaches. Blood pressure is found to be 210/130, pulse 72. All blood work is normal and the EKG shows LVH by voltage criteria. Prompt treatment yielded a nice improvement in BP to 130/80. A pronounced S4 is present on heart exam.

Hypertension-75 million US adults suffer from hypertension. (26% adults worldwide). 95% is idiopathic (primary; or essential). Secondary causes are renal artery stenosis (RAS), cortisol excess (Cushing’s disease), obesity, hyper-thyroidism, pheochromocytoma, and aortic coarctation. Consequences of HTN include stroke, CAD, PVD, CHF, diastolic dysfunction, aortic aneurysm, dementia, and CKD. Treatment- diuretics (thiazides,loop- a)furosemide b) ethacrynic acid-no sulfa, K-sparing- a) amiloride b) triamterene c) spironolactone d) eplerenone- like spironolactone but less gynecomastia, helps in CHF pts.) ACE inhibitors- less helpful in Black patients, good in CHF after MI, or reducing proteinuria in DM, ARBs- similar to ACE, but less cough, Beta-blockers- a)labetalol b) carvedilol c) nebivolol, Calcium-entry blockers- vasodilators and decrease TPR, Direct vasodilators- a) hydralazine b) minoxidil, Alpha-blockers-peripheral- a) doxazosin,b) terazosin and central- clonidine, Renin inhibitors (Aliskiren). For Blacks, use diuretics and Calcium channel blockers first. In hospital Rx- IV hydralazine, labetolol, or IV vasotec. Stay away from HCTZ and Lasix in gout patients. Think of Carvedilol, Metoprolol, ACE Inhibitors, and spironolactone in setting of CHF. Beta blockers, Dihydropyridines and Calcium blockers will cause pedal edema. Use Thiazides in Calcium stone patients. Alpha-blockers like Terazosin are great in patients with BPH. Spironolactone is a good choice when rosacea is present. Minoxidil use will also require Lasix and a beta-blocker to combat edema and tachycardia. DASH (Dietary Approaches to Stop Hypertension)-good diet.

Stress Tests (Sensitivity= 80%; Specificity >90%)- Bruce protocol is the standard method. 2 or 3 minute stages for speed and elevation. Hold beta-blockers, Calcium blockers, nitrates. Watch for functional aerobic impairment. Goal is > 6 mets of work. Goal is achieving 85% of predicted HR. Sestamibi is standard nuclear isotope tracer for walking stress tests. Monitor for EKG changes and arrythmia. Dobutamine is a beta-agonist used for a chemical stress test.

Adenosine (hold caffeine) or Lexiscan (regadenoson)-vasodilators, are also used for chemical stress test. Watch for low BP, heart block, flushing, SOB, GI affects. Adenosine is contraindicated in asthma/COPD. When to use stress-echo? To check heart wall motion and valvular function during stress.

Pheochromocytoma-Neuroendocrine tumor of the adrenal medulla. Over-production of catecholamines. Symptoms- uncontrolled HTN, tachycardia, HA, anxiety, weight loss, diaphoresis, palpitations. Can be familial in 25%. Can be part