VIMG Past Cases
Case 1, Alfred Health, 3rd October 2023
Presenter: Dr Noor Lammoza
Title: ‘A Corker of a Case’
Noor presented a case of modern scurvy. Mr DB, a 45yom current IV drug user with a history of alcohol use disorder.
Mr DB presented with a 3 week history of general malaise, bilateral mostly lower and some upper limb petechial rash and a swollen left thigh.
Investigations revealed an iron deficiency anaemia, CRP 54 with a normal platelet count and coagulation studies. Ultrasound followed by CTA, MRI and knee and thigh aspirates alongside orthopedics and vascular consults, revealed a hemarthrosis and vastus medialis haematoma with surrounding non-necrotising myositis/fasciitis.
Biopsy of a skin lesion on the arm showed solar keratosis. The diagnosis was made on dermatology review based on the presence of corkscrew hairs! A pathognomonic sign for scurvy with follicular haemorrhage and twisted fragile hairs alongside hyperkeratotic lesions. This prompted testing of vitamin C levels, which were undetectable.
On further questioning Mr DB had consumed only iced coffee for the last four months in the setting of a deterioration in his mental health. Besides iron, other nutritional markers were unremarkable including B12, folate, Vit D and trace minerals. After vitamin C loading 1g/day his symptoms improved. He had limited engagement with psychiatry review. He discharged once his mobility improved and did not attend follow up.
This case prompted discussion on the differentials for petechiae and spontaneous haemorrhage with normal platelet counts and coagulation studies.
The take home messages: Consider nutritional deficiencies in those at risk. Vitamin C levels should be reserved with those with a high level of suspicion based on the clinical picture and dietary history. Vitamin C deficiency and scurvy may go unrecognised in the General Medicine population and this is an area for further research.
Case 2, Eastern Health, 17th October 2023
Presenter: Dr Osto Ramasokola
Title: ‘Is it Silent?’
Mrs ZI, A 62 year old woman with a history of Parkinson’s Disease and Schizoaffective Disorder presents with one week of confusion.
Initial examination reveal signs of parkinsonism and myoclonic jerks with no other focal neurology. Her medications include madopar, lithium, venlafaxine, risperidone, vitamin D and movicol.
Differentials considered:
Infection: UTI/pneumonia causing delirium, CNS infections eg. herpes encephalitis, CJD
Medications: Lithium toxicity, Serotonin syndrome or Neuroleptic Malignant Syndrome
Inflammatory: Autoimmune encephalitis
Metabolic: Hypercalcemia, uremia, hepatic encephalopathy, thyrotoxicosis
Investigations show a microcytic anemia , unremarkable electrolytes, liver and baseline renal function with a CRP of 10. Lithium level 2.0 (0.6 - 0.8)
Mrs Z.I becomes increasingly obtunded, develops a low grade fever 37.8 and becomes increasingly hypernatremic and polyuric.
The diagnosis of lithium toxicity causing neurotoxicity and nephrogenic diabetes insipidus is made. She was transferred to ICU with consults from toxicology, nephrology and neurology.
Treatment with 1:1 IV hydration. DDAVP due to persistent hypernatremia and dialysis commenced due to neurological symptoms. Empiric antibiotics for meningoencephalitis were ceased after an unremarkable LP.
Despite undetectable lithium levels and correction of electrolytes Mrs ZI has ongoing confusion.
SILENT Syndrome: Syndrome of Irreversible Lithium Effectuated Neurotoxicity
Patient Progress
Incomplete neurological recovery with some ongoing confusion and deconditioning after prolonged hospital stay. Discharged for home based rehabilitation.
Consideration that her longstanding tremors and reduced mobility are likely due to chronic lithium toxicity rather than Parkinson’s Disease. Lithium, risperidone and venlafaxine are ceased. Discharged on Quetiapine and desvenlafaxine for ongoing psychiatry and neurology follow up.
This case raised awareness of the different presentations of lithium toxicity and prompted discussion on deprescribing with advancing age.
Case 3. Specialty Topic: Addiction Medicine.
Dr Martyn Lloyd-Jones, Alfred Health, Royal Melbourne Hospital and Eastern Health
Addiction Medicine Specialist Dr Martyn Lloyd-Jones explored the complexity behind caring for patients with alcohol and drug addiction. He examined historical and epidemiological perspectives and considered factors that make some populations more vulnerable. With an emphasis on trauma informed care and reference to neurobiology Dr Lloyd-Jones discussed some of the challenges in providing hospital based care which prompted discussion on some of the ethical dilemmas we face in General Medicine.
Case 4. Ballarat Base Hospital
Dr Dimitri Markus, Respiratory and General and Acute Care Medicine Advanced Trainee
Dimitri Markus from Ballarat Base Hospital presented a case of non-epileptiform seizures. Markus walked us through the process of arriving at the diagnosis and an approach to management. He provided an update on the risk factors and epidemiology with a particular emphasis on the morbidity, mortality and health care cost of this condition being comparable to that of epileptiform seizures.
Case 5. Royal Melbourne Hospital
Dr Julia Sewell, Rheumatology and General Medicine Advanced Trainee
A 32 year old man presents to a regional hospital with tiredness and is
found to have a profound macrocytic anemia, Hb 24 with some but not all
features of haemolysis including an elevated bilirubin and LDH with
positive DCT but normal haptoglobin and no fragments on blood film.
He
has serology in keeping with SLE and antiphospholipid syndrome and is
later found to have myocarditis and lung involvement. In consultation
with rheumatology and haematology he is treated for both SLE and
catastrophic antiphospholipid syndrome with a significant improvement in
his symptoms. This case highlighted the differential diagnosis and
work up of anaemia and haemolysis in a young person and generated
multidisciplinary discussions on the potential differentials and factors
considered when initiating treatment.