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Case Reviews

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Case 1

A 33-year-old man has A low HDL level.

Should you treat him?

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Case #1

A 33-year-old male had a fasting lipid profile as a part of his regular screening.

Past medical history (PMH) and family medical history (FMH)

Negative.

Medications

None.

Fasting lipid profile

Triglycerides 100 mg/dLTotal cholesterol 192 mg/dLHDL 36 mg/dLLDL 136 mg/dL

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What is abnormal?

Fasting lipid profileTriglycerides 100 mg/dLTotal cholesterol 192 mg/dLHDL 36 mg/dLLDL 136 mg/dL

HDL is low.HDL is low.

LDL is mildly elevated.LDL is mildly elevated.

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Should you treat an isolated low HDL level?

No medications are recommended.No medications are recommended.

Drug therapy is advised in patients with low HDL if the 10-year Framingham risk score is more than 20% or if the patient has a significant FMH of early CAD. ATP III provides a free online calculator of Framingham risk score.

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What is treatment for low HDL?

Statins are often used but they cause only a modest increase in HDL level by 5-10%.

Niacin is more potentmore potent (30% HDL increase) but less well tolerated than statins (90% of patients complain of flushing).

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What lifestyle interventions can raise HDL?

Aerobic exerciseAerobic exercise can raise HDL level by 10%-20%. Daily alcohol consumption raises HDL level by 5-10%.

Weight lossWeight loss does not always have a positive short term affect on lipid levels.

For each kilogram of weight lost during active dieting, HDL levels falls by 8%.HDL levels falls by 8%. Once weight is stabilized, there is a mild increase in HDL.

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Why is HDL cardioprotective?

HDL participates in moving cholesterol from peripheral tissue to the liverperipheral tissue to the liver. It also has an antioxidantan antioxidant effect.

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Can dietary changes help?

Adding mono-unsaturated fats and a vegetable enriched diet helps.

Reference:http://www.cmaj.ca/cgi/rapidpdf/cmaj.0921

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Case 2

A female with asthma and allergic rhinitis Who is trying to become pregnant:

What medication changes may be needed?

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History A 27-year-old Caucasian female is seen for allergic rhinitis and

asthma. She is on immunotherapy (grasses, trees, ragweed, weeds, cat,

dust mite), started one year ago. She stopped using Advair on her own 6 months ago and currently

reports symptoms of asthma 2 times per week which are partially relieved by a rescue inhaler use.

She has had no nighttime symptoms and no emergency room visits in the past year. She reports symptoms of allergic rhinitis, although since she started immunotherapy, the symptoms are mostly seasonal, limited to runny nose in the fall.

She has been trying to become pregnant for the last 2 months and Wants to know if any medication changes may be needed.Wants to know if any medication changes may be needed.

PMHPMH

Asthma, allergic rhinitisAsthma, allergic rhinitis

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MedicationsDallergy* b.i.d. for three days around the time of each allergy shot.

She receives the immunotherapy every week. Fluticasone**, nasal spray. She also takes a prenatal multivitamin daily and

she stopped using Advair (fluticasone/salmeterol***) 6 months ago.

*Chlorpheniramine/Phenylephrine/Methscopolamine **steroid-pregnancy category C ***(sal-ME-ter-ol) LABA-used to preventprevent asthma attacks

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Physical examination

Well-developed, well nourished in no apparent distress.

Vital signs: T98.5, P 81, R 12, BP 120/60. Skin: No rash. Ears: Normal. Nose: Boggy, pale turbinates. Ears: Normal. Chest: Clear to auscultation bilaterally. Cardiovascular: Clear S1, S2. Extremities: No edema or clubbing.

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Lab Test

Spirometry shows FVC of 100%, FEV1 of 89% and FEV1/FVC of 0.79 (healthy adults this should be approximately 75–80%)

Her ACT score is 18/25.

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?ACT= Asthma Control Test

5- question assessment toolRange of 5 to 25 19 or less: asthma not under control visit www.asthmacontrol.com http://www.allergytampa.com/Portals/314/Skins/pb-loc/pdfs/MEDS-OV.pdf

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Should she change her medications for allergic rhinitis?

In light of the fact that she is trying to become pregnant, we recommended a category B intranasal steroid -- category B intranasal steroid -- Rhinocort Aqua (budesonide)Rhinocort Aqua (budesonide) one spray daily one spray daily.*

Advise her against using medications such as Allegra (fexofenadine) or Dallergy (chlorpheniramine, phenylephrine, and methscopolamine), which may have an adverse affect on the fetus.

Recommend Zyrtec (cetirizine) prnZyrtec (cetirizine) prn whenever she has symptoms because Zyrtec is pregnancy category B.

*Most intranasal steroids (INS) have a pregnancy C rating.

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Can immunotherapy be continued if the patient is on it and becomes pregnant?

Yes, immunotherapy can be continued at the maintenance dose. There should not be a dose escalation during pregnancy.

The immunotherapy dose should not be increased in a pregnant patient until after delivery.

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Can immunotherapy be started if a patient is pregnant or planning to become pregnant?

No. It is generally not recommended to start immunotherapy if a patient is pregnant or planning to become pregnant.

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What did we learn from this case?

In pregnant patients or in patients trying to conceive who have allergic diseases, physicians should prescribe medications which are rated category B whenever possible.

Examples of pregnancy category B medications:- inhaled steroids: budesonide (Pulmicort)- intranasal steroids: budesonide (Rhinocort Aqua)- antihistamines: cetirizine

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Case 3

ACase

Of Food Allergy

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An 8-year-old boy is seen by his pediatrician for follow-up of abdominal pain.

He had already visited the ER last week for RLQ abdominal pain and acute appendicitis had been ruled out.

He complained of abdominal pain radiating to RLQ, nausea, vomiting, lack of appetite and weight loss for 6 months.

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Past medical history (PMH)Allergic rhinitis and conjunctivitis for 3 years, skin prick testing positive for house dust mite (2 years ago)

Fast medical history (FMH) Mother with allergic rhinitis.

Medications Prevacid (lansoprazole) daily.

Pets Outdoor hunting dogs.

Physical examination Diffuse abdominal tenderness, no rebound, normal BS, otherwise

normal.

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What would you do? Refer to a gastroenterologist who performed an

EGD which showed 19 eosinophils per HPF. "Multi-ring esophagus" in eosinophilic esophagitis (left), infiltration of eosinophils (right).

Diagnosis: Eosinophilic esophagitis.

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?Treatment

Fluticasone (Flovent) PO was started with rapid resolution of symptoms within 2-3 weeks. The patient's appetite improved greatly and he gained 10 pounds during a 6-month period.

Pulmicort (budesonide) Respules, 0.5/2 mL PO bid may work better than fluticasone spray since the patients actually drinks the viscous liquid rather than using a spray.

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Does he need a biopsy in the future?

Yes, a repeat biopsy should be done to verify the effect of the treatment.

PPI augments the therapeutic effect of inhaled fluticasone and a combination therapy (ICS plus PPI) should be used in all patients.

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What are the typical symptoms of eosinophilic esophagitis in different age groups?

Infants present with vomiting.Children present with abdominal pain and vomiting.Older children present with the feeling that the "food is stuck."

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What is the prognosis for resolution of eosinophilic esophagitis?

Uncertain.

85% of children with atopic dermatitis eventually become asymptomatic.85% of children with asthma eventually become asymptomatic.50% of children with allergic rhinitis eventually become asymptomatic.

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Case 4

Diabetic Foot

Infection of

Stasis Ulcers

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A 58-year-old African American male (AAM) was admitted from a nursing home (NH) with a chief complaint (CC) of being lethargic and not acting appropriately. The patient stated that his legs hurt, and they had been hurting for a long time, and he rated his pain as an 8 on a scale of 1 to 10.

Past medical history (PMH)

Diabetes type 2 (DM2), hypertension (HTN), venous stasis ulcers, hepatitis C, peripheral vascular disease (PVD), congestive heart failure (CHF).

Past surgical history (PSH)

Bilateral (B) LE stasis ulcers status post (S/P) extensive debridements of both lower extremities and multiple failed skin grafts 2 years ago, right hallux amputation.

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MedicationsAcetaminophen (Tylenol),

Ambien (zolpidem), hydrocodone, FeSO4, clonidine, amitriptyline, Oxycontin (oxycodone, Lantus (insulin glargine), furosemide (Lasix), metformin, Actos (pioglitazone), metoprolol.

Social history (SH)A remote history of heroin and cocaine abuse, former smoker and drinker.

Physical examinationVS 38-126-24-137/81.Chest: clearCVS: tachycardic but regular with no murmurs.Abdomen: Soft, NT, ND, +BS.

Extremities:Extremities: Severe venous stasis ulcers of the lower extremities, approximately 1/2 way down and almost circumferential.

The ulcers are full thickness and third-degree. There is a good granulation tissue.

Neuro: He is slow to respond to questioning. No focal neurological deficits apart from diminished sensation on (B) LE.

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Diabetic patient with (B) infected stasis ulcers. There is Diabetic patient with (B) infected stasis ulcers. There is only a small bridge of tissue covering the back of the right only a small bridge of tissue covering the back of the right leg and the front of the left shin.leg and the front of the left shin.

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Left leg stasis ulcer. Note the Left leg stasis ulcer. Note the hypertrophic granulation tissue at the hypertrophic granulation tissue at the bottom of the ulcer and the small bridge bottom of the ulcer and the small bridge of skin at the frontof skin at the front

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Right leg stasis ulcer. Note the previous hallux amputation Right leg stasis ulcer. Note the previous hallux amputation and the grey-blue discoloration at the bottom of the ulcer. and the grey-blue discoloration at the bottom of the ulcer. This grey-blue to green discoloration may indicate a This grey-blue to green discoloration may indicate a Pseudomonas infectionPseudomonas infection.

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What labs would you order?

CBCD, CMP, UA.Wound culture, BCx x 2.X-rays.

BUN was 51 mg/dL and creatinine 2.5 mg/dL. Hgb 8.8 mg/dL.

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What are the questions to ask now?

What is his baseline?

A review of the old medical records, showed a BUN of 14 mg/dL and creatinine of 1.3 mg/dL, seven months ago.

WBC was 17.1/mm3, hemoglobin 8.8 mg/dL, hematocrit 26.7, hypochromic, microcytic peripheral smear. The differential showed 69 neutrophils and 11 bands.

The patient has an infection and he is probably dehydrated which may explain the rise in the BUN/Cr. Mucosal membranes were dry.

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Antibiotic therapy

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What did we learn from this case?

Diabetic foot infections should be treated promptly with the appropriate antibiotics.

A blue-green wound exudate may indicate Pseudomonas, and Zosyn (Piperacillin and Tazobactam) or other antibiotic with a good antipseudomonas coverage is needed.

The management of diabetic foot ulcers is complex and involves wound care, surgery or podiatry and PT/OT.