CPC

1
CPC 2 Plumbism or Promiscuity?
Bridging the Gap. Where Clinical and Basic
Sciences Meet

• Amit Malhotra, MD
• Fellow, Cardiovascular Diseases

Louisa Balazs, MD, PhD Associate Professor of
Pathology
Karl T. Weber, MD Professor of Medicine
2
Friday morning, September 9, 1956, and Birmingham
was abuzz ? with the prospects of the Tide having
another successful season without that Yankee
from Beaver Falls, Pennsylvania, at quarterback.
The responsibility for this season would fall on
the lefty from Muscle Shoals, Alabama. In the
Universitys outpatient clinic, the ceiling fan
made its futile attempt at circulating humid air.
Second-year internal medicine resident, Nick
Bailey, had just handed a prescription for
isoniazid to a 24-year-old woman whose tuberculin
skin test had recently converted when he noticed
his next patient,
3
Friday morning, September 9, 1956, and Birmingham
was abuzz with the prospects of the Tide having
another successful season ? without that Yankee
from Beaver Falls, Pennsylvania, at quarterback.
The responsibility for this season would fall on
the lefty from Muscle Shoals, Alabama. In the
Universitys outpatient clinic, the ceiling fan
made its futile attempt at circulating humid air.
Second-year internal medicine resident, Nick
Bailey, had just handed a prescription for
isoniazid to a 24-year-old woman whose tuberculin
skin test had recently converted when he noticed
his next patient,
4
Friday morning, September 9, 1956, and Birmingham
was abuzz with the prospects of the Tide having
another successful season without that Yankee
from Beaver Falls, Pennsylvania, at quarterback.
? The responsibility for this season would fall
on the lefty from Muscle Shoals, Alabama. In the
Universitys outpatient clinic, the ceiling fan
made its futile attempt at circulating humid air.
Second-year internal medicine resident, Nick
Bailey, had just handed a prescription for
isoniazid to a 24-year-old woman whose tuberculin
skin test had recently converted when he noticed
his next patient,
5
Friday morning, September 9, 1956, and Birmingham
was abuzz with the prospects of the Tide having
another successful season without that Yankee
from Beaver Falls, Pennsylvania, at quarterback.
The responsibility for this season would fall on
the lefty from Muscle Shoals, Alabama. ? In the
Universitys outpatient clinic, the ceiling fan
made its futile attempt at circulating humid air.
Second-year internal medicine resident, Nick
Bailey, had just handed a prescription for
isoniazid to a 24-year-old woman whose tuberculin
skin test had recently converted when he noticed
his next patient,
6
Friday morning, September 9, 1956, and Birmingham
was abuzz with the prospects of the Tide having
another successful season without that Yankee
from Beaver Falls, Pennsylvania, at quarterback.
The responsibility for this season would fall on
the lefty from Muscle Shoals, Alabama. In the
Universitys outpatient clinic, the ceiling fan
made its futile attempt at circulating humid air.
Second-year internal medicine resident, Nick
Bailey, had just handed a prescription for
isoniazid to a 24-year-old woman whose tuberculin
skin test had recently converted when he noticed
his next patient,
7
Mr. L., carefully negotiating the doorway to the
examining room. This disheveled-appearing
44-year-old had a wide-based gait and a right leg
that slapped at the floor. Mr. L. complained of
weight loss, postprandial bloating relieved by
vomiting, as well as shooting pains in his sides.
8
For 15 years he had been gainfully employed as a
painter. ? More recently he had worked in a
downtown movie theater, but lost this job when
patrons complained he dropped both their tickets
and his torch as he staggered drunk-like down
the aisle ushering them to their seats.
9
For 15 years he had been gainfully employed as a
painter. More recently he had worked in a
downtown movie theater, but lost this job when
patrons complained he dropped both their tickets
and his torch as he staggered drunk-like down
the aisle ushering them to their seats.
10
He fondly recalled several tours of duty with the
Navy from 1941 to 1945 and during the great
conflict his voyages aboard the USS Missouri ? to
the Pacific included many inviting ports of call
where he could comport himself with great
alacrity and indeed reckless abandon.
11
He fondly recalled several tours of duty with the
Navy from 1941 to 1945 and during the great
conflict his voyages aboard the USS Missouri to
the Pacific included ? many inviting ports of
call where he could comport himself with great
alacrity and indeed reckless abandon.
12
He fondly recalled several tours of duty with the
Navy from 1941 to 1945 and during the great
conflict his voyages aboard the USS Missouri to
the Pacific included many inviting ports of call
where he could comport himself with great
alacrity and indeed reckless abandon.
13
And, as was the case for many folk livin in the
rural South, Mr. L admitted to an occasional
taste o shine, or moonshine whisky, ? that he
and his pals prepared using a homemade distilling
apparatus that included an old car radiator.
14
And, as was the case for many folk livin in the
rural South, Mr. L admitted to an occasional
taste o shine, or moonshine whisky, that he
and his pals prepared using a homemade distilling
apparatus that included an old car radiator.
15
On examination, blood pressure 140/50, pulse
84/min, 14 bpm. Examination of eyes, ears, nose,
neck, throat and lung fields were unremarkable.
Apical pulse was displaced leftward and in the
2nd right and left intercostal space a diastolic
murmur was audible. Abdomen was benign.
16
The right knee was hypermotile and loose
fragments were felt in the joint space vibratory
sensation was absent in both legs. On standing
and with his eyes closed, the patient swayed from
side to side.
17
Nick considered whether the patients illness was
a consequence of plumbism or promiscuity. After
all, there was commonality between the two.
Furthermore, would he prescribe penicillamine or
penicillin? The patient was admitted for further
evaluation and treatment.
18
Plumbism or Promiscuity

• Clinical-Pathological Conference Series
• October 21st, 2004

Divisions of Cardiovascular Diseases and
Pathology University of Tennessee Health Science
Center, Memphis
19
Historical features of note

• Middle aged male
• Recent onset of symptoms
• History of possible exposure to lead
• employment as a painter for 15 years
• moonshine whiskey distilled in a radiator
• Lifestyle possible STDs

20
Symptoms and Signs

• GI post-prandial bloating and weight loss
• CVS wide pulse pressure, diastolic murmur and
  cardiomegaly
• Neurological Ataxia worse in darkness, absent
  vibratory sensation in both lower extremities,
  right sided foot drop, Positive Rombergs sign
• Musculoskeletal Deformity of the right knee with
  hypermotility and loose bodies

21
Disorders that cause multi - system involvement

• Vascular/rheumatologic
• Infectious
• Metabolic/Endocrine
• Malignancy
• Congenital syndromes

22
Post prandial bloating and weight loss

• Obstructive
• Neurological
• Vascular

23
Cardiovascular

• Wide pulse pressure
• Diastolic murmur
• Cardiomegaly

24
Neurological

• Ataxia
• Shooting pains
• Absent vibratory sensations in legs

25
Musculoskeletal

• Neuropathic joint

26
Differential Diagnoses

• Tertiary syphilis with aortitis, tabes dorsalis,
  and gastric involvement
• Lead poisoning with abdominal symptoms, and
  neuropathy

27
Lead poisoning

• Anemia
• Hypertension
• Saturnine gout
• Very rarely, dilated cardiomyopathy
• Peripheral neuropathy

28
Tertiary syphilis

• Luetic aortitis with aortic insufficiency due to
  aortic root disease
• Syphilitic hyperplastic gastritis (linitis
  plastica) vs. Gummatous pyloric obstruction
• Tabes Dorsalis posterior column disease and
  sensory ataxia and nueropathic pains
• Charcots joint

29
PLUMBISM OR PROMISCUITY
30
Chronic lead poisoning
31
Treponema pallidum
32
Treponema pallidum-dark field microscopy
33
Syphilis-skin lesions
34
Tabes dorsalis-spinal cord
35
Luetic aortitis
36
Luetic aortitis
37
In 1966, lead poisoning could still be found in
painters. It also was common in those who
imbibed illegally distilled whisky. Plumbism is
accompanied by colicky abdominal pain, peripheral
neuropathy with paralysis of often-used muscle
groups (e.g., foot drop) and ataxia. ? Basophilic
stippling and increased urinary coproporphyrin
levels would be expected.
38
In 1966, lead poisoning could still be found in
painters. It also was common in those who
imbibed illegally distilled whisky. Plumbism is
accompanied by colicky abdominal pain, peripheral
neuropathy with paralysis of often-used muscle
groups (e.g., foot drop) and ataxia. Basophilic
stippling and increased urinary coproporphyrin
levels would be expected.
39
Tabes dorsalis likewise is associated with
ataxia, but with posterior column and root
involvement, a characteristic wide-based gait and
slapping movement of an affected leg occurs ?
with subsequent joint destruction (Charcot
joint) position sense falters with eyes closed
(Rombergs sign) or when interior lighting is
reduced.
40
Tabes dorsalis likewise is associated with
ataxia, but with posterior column and root
involvement, a characteristic wide-based gait and
slapping movement of an affected leg occurs with
subsequent joint destruction (Charcot joint)
position sense falters with eyes closed
(Rombergs sign) or when interior lighting is
reduced.
41
Patients with tertiary syphilis experience
lightning-like pains of the abdominal wall and
lower extremities ? gastric gummas can create
pyloric outlet obstruction. Luetic aortitis
leads to dilatation of the ascending aorta and
valvular incompetence. As a result, the murmur
of aortic regurgitation is heard in both the
right and left upper thorax. Nick would find
intramuscular penicillin his drug of choice.
42
Patients with tertiary syphilis experience
lightning-like pains of the abdominal wall and
lower extremities gastric gummas can create
pyloric outlet obstruction. ? Luetic aortitis
leads to dilatation of the ascending aorta and
valvular incompetence. As a result, the murmur
of aortic regurgitation is heard in both the
right and left upper thorax. Nick would find
intramuscular penicillin his drug of choice.
43
Patients with tertiary syphilis experience
lightning-like pains of the abdominal wall and
lower extremities gastric gummas can create
pyloric outlet obstruction. Luetic aortitis
leads to dilatation of the ascending aorta and
valvular incompetence. As a result, the murmur
of aortic regurgitation is heard in both the
right and left upper thorax. Nick would find
intramuscular penicillin his drug of choice.
44
Penicillin will reduce gastric gumma size ? and
regress aortic remodeling.
45
Penicillin will reduce gastric gumma size and
regress aortic remodeling.