How To Use Imaging In The Diagnosis Of Difficult Medicine
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- Eleanor Carroll
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1 Scanning for Answers: Using Imaging in the Diagnosis of Difficult Medicine Cases This lecture will concentrate on internal medicine case presentations in which diagnostic imaging was incorporated in the diagnostic workup. Specifically, 3 individual cases will be presented, including a patient with hypercalemia, one with suspect Cushing s disease and one with hyperglobulinemia. The lecture will briefly describe rule outs for these problems and the diagnostic approach for each problem. Dr. Gall will describe various imaging techniques which can be utilized to help with the diagnostic workup.
2 Toby 10 yr old MN Border Collie cross cc: decreased appetite, increased thirst.
3 Toby Blood Work Urinalysis Calcium = 14.0 SG = Phos = ca oxalate Bun = 36 Creat = 2.7 CBC = Normal Na = 147 K = 4.4 Recheck Calcium = 13.6
4 Hypercalcemia Clinical Signs Renal: PU/PD (70%) UTI, Calculi Neuro: GI: Listlessness Weakness Anorexia Vomiting
5 Hypercalcemia Physical Examination Lymph Nodes Rectal Exam Mammary Chain Abdominal Mass? Lameness/swelling
6 Hypercalcemia Blood Work Ca > 14.0 Phosphorus: low or normal Humoral Hypercalcemia of Malignancy Primary Hyperparathyroidism
7 Hypercalcemia Blood Work Ca > 14 Hyperphosphatemia Multiple Myeloma Primary HyperPTH with CRF Humoral HyperCal of Malignancy w/crf Primary or metastatic bone cancer Vitamin D toxicity Hypoadrenocorticism
8 Hypercalcemia Blood Work Mild hypercalcemia/hyperphos CRF Neoplasia, with CRF or dehydration Primary hyperparathyroidism with CRF and/or dehydration Addison s Bone tumor/lysis Vitamin D toxicity
9 Hypercalcemia Elevated with: Blood Work Ionized Calcium Primary PTH, Lymphosarcoma, apocrine gland adenocarcinoma Normal to low: CRF
10 Toby Diagnostic Workup Lateral abdo rad: cystic calculi Resting Cortisol: 2.5 ug/dl Abdominal US: renal mineralization, cystic calculi PTH assay Thoracic rads?
11 Toby PTH = 7.4 (N = pmol/l) Ionized Ca = 2.27 (N = MMol/L) PTHrP = 0.0
12 Hypercalcemia
13 Toby Presented to VCA NWVS for cervical ultrasound and possible surgery.
14 Scanning technique for thyroid/parathyroid
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19 LEFT THYROID RIGHT THYROID
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21 Toby Surgery 1 cm nodule cranial left thyroid Histopathology: adenoma Stone analysis: Calcium Oxalate
22 Oscar 13 yr old nm Dachshund Slowly increasing SAP levels (n=5-31) 12/09 SAP = 325 ALT and Chol = wnl 6/10 SAP = 403 UPC = 0.7 8/10 SAP = 634 SG = /10 Bile acids = 32 and 16 umol/l 12/10 SAP = 1,241 Chol = 356 Alt = wnl
23 Oscar Further Diagnostics 12/10 Bile Acids = 16 and 37 UPC = 2.2 US = Generalized hepatomegaly, adrenals normal Liver cytology: Vacuolar hepatopathy. Treatment: Vit E, aspirin, Denamarin, enalapril
24 Oscar 7/11 SAP= 3281, ALT = 188, Chol = 491 UPC = 4.3 Bile Acids = 16, 38 Urine SG = Not overly PU/PD, always has good appetite, slightly distended abdomen
25 8/11 ACTH Stim = pre 1.2, post = 6.7 UPC = 2.2 Clinically doing well. Oscar 7/11 ACTH Stim = pre 3.9, post = 31.4 Repeat US Slightly enlarged adrenal glands (8.1, 7.0) Started oral Trilostane at 10 mg BID
26 Oscar 12/11 SAP = 481; ALT = 101; Chol = 315 ACTH Stim: pre = 1.5, post = 2.1 Bile acids: pre = 14, post = 24 UPC: 2.9 Clinically doing well, good energy, abdomen less distended?, not PU/PD, good appetite. Decreased Trilostane to 7.5 mg BID
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31 Cora Sig: 8 yr sf Pitbull Terrier CC: Possible PU/PD Gammopathy (tp = 8.2) Hypoalbuminemia (1.9)
32 Cora History Rescued in Oakland Calif. Spent 5 months with foster family before recent adoption and move to Portland. No vomiting, diarrhea, or weight loss. Good appetite.
33 Hyperglobulinemia Polyclonal vs. Monoclonal Protein electrophoresis. Hypoalbuminemia Liver, PLN, PLE With gammopathy decreased liver production?
34 Differentials Polyclonal: any infectious, neoplastic or inflammatory process Monoclonal: Ehrlichia Multiple Myeloma Lymphoma/neoplasia Plasmacytoma
35 Cora Diagnostic Work Up Ehrlichia/tick panel: Negative Thoracic radiographs: Normal Electrophoresis: Polyclonal Urinalysis: SG = 1.010, 2+ protein UPC: 2.0 (n= < 0.5)
36 Cora Diagnostic Work Up Abdominal Ultrasound
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39 Cora Cytology results Spleen: Lymphoid hyperplasia Mass: Malignant Neoplasia; exact origin uncertain.
40 Cora Diagnostic Work UP Thoracic and abdominal CT scan.
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42 Cora Histopathology: Pheochromocytoma Possible adrenal in origin? However, adrenal gland was normal during exploratory.
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