Case presentation

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Case presentation

• By Dr.Sujith

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• 38 year old lady
• ? k/c/o epileptic
  disorder
• ? Nasal Furuncle x 3
  months
• Presented with c/o
• Right sided Headache x 2 weeks

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• Right sided Headache
• Severe
• Constant in nature,
• Associated with swelling around the Rt eye
• Redness
• No Pain on movement of the eyes
• No past h/o headache

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• On treatment from Ophthalmology, ENT,Neurology
  -gt 2 weeks
• Antibiotics,analgesics-gtPoor response

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Clinical Examination

• Conscious and oriented
• No pallor/icterus/ cyanosis/ clubbing/lymphadenopa
  thy/ edema
• PR 80/min, regular, normal character volume ,
  all peripheral
• pulses palpable
• BP 124/76 mm Hg
• RR 18/min SpO2 99 at room air.
• Temp 98.6 deg F
• Thyroid -no swelling

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Local Examination

• Swelling over the right periorbital region.
• Redness severe tenderness over the region
• No proptosis

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Systemic Examination

• NS
• HMF N, CNWNL
• Motor system WNL, Sensory system WNL
• No signs of meningeal irritation, No cerebellar
  signs
• Skull spine normal.
• Fundus - Normal
• P/A
• Soft, non tender, no organomegaly
• RS
• B/l Normal vesicular breath sound, No crepts/
  wheeze
• CVS
• S1S2 heard, No murmurs

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Provisional Diagnosis

• Patient on treatment from Ophthalmology ,ENT
  neurology for past 2 weeks
• Initial Imp
• ?Ophthalmology orbital cellulitis
• ?ENT-Right frontal sinusitis
• ?Neurology-?cluster headache,
• Cavernous Sinus
  Thrombosis

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• ?On multiple antibiotics x 2 weeks
• ?No Response
• Hence came to Med Dept.
• Additional findings noted
• i)temp98.6 F
• ii)severe tenderness
  over the Rt
• temporal artery.
• iii)No h/o shoulder
  pain/muscle
• stiffness.
• iv)Visual
  acuity,field Fundus-N

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• Hb 11.6 gm
• HCT 33.5
• MCV 86 fl
• MCH 30.4 pg
• MCHC 35.4 g/dl
• TC 13,200, N-63, L-28.5
• RBC4 million/uL
• Plt310000Ku/ml
• ESR20 ?30mm/hr

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• Total Bilirubin 0.34mgdl
• Direct Bilirubin0.09mg/dl
• SGOT 18.4 IU/L
• SGPT 30.2 IU/L
• ALP65 IU/L
• T.Protein 7.2 gm/dl
• S.Albumin 4.08 gm/dl
• S.Globulin 3.1 gm/dl

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• Sr. Urea23.7mg/dl
• Sr. Creatinine 1mg/dl
• S.Na142.1mEq/L
• S.K4.1mEq/L
• S.Ca8.5mg/dl
• S.Ph3.5mg/dl
• CRP1.67 mg/L
• Total CK149

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• Peripheral Blood SmearNormocytic Normochromic
  blood picture with leucocytosis
• USG AbdomenLeft Ovarian Cysts(follicular)

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• She was advised urgent admission ,but refused.
• Suspected temporal arteritis,started on
  T.Prednisolone 1mg/kg/day.
• Came after 5 days for admission temporal artery
  biopsy.
• Within 5 days ?i)edema improving
• ii)Headache
  subsided

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• Meanwhile earlier reports available-
• i)ENT-Nasal Endoscopy-gtNo evidence of
  sinusitis/nasal furuncle.
• ii)MRI Brain MRV-gtNormal Cavernous sinus
  tributaries.Orbital soft tissue normal.

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• ANA ScreenBorderline
• Anti dsDNA22.6IU/ml
• cANCAnegative
• pANCAnegative

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Biopsy

• Temporal Artery Biopsy Focal Calcification seen
  in the media
• No evidence of active inflammation at present .
• There is no evidence of calcification in the
  intima Internal Elastic Lamina.

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Case reportsOnly in Patients with Chronic Renal
Failure

• Calciphylaxis of Temporal Artery masquerading as
  temporal arteritis
• Clinical Experiment OphthamologyDepartment of
  OphtalmologyAmerican Unniversity of Bierut
  Medical Centre,Bierut,Lebanon
• Medial arterial calcification mimicking temporal
  arteritis.
• Al-Absi AI, Wall BM, Cooke CR.
• American Journal of Nephrology
• Department of Nephrology, University of Tennessee
  Health Science Center, Veterans Affairs Medical
  Center, Memphis, TN 38104, USA

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Dystrophic Calcification

• Encountered in areas of necrosis.
• egatheromas of advanced atherosclerosis,intimal
  injury in the aorta
• large arteries
• A cause of organ dysfunction .
• Normal serum levels of Calcium
• HistopathologicallyIntracellular extracellular
  basophilic deposits.

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Metastatic Calcification

• Can occur in normal tissues.
• Deranged calcium metabolism-hypercalcaemia
• Causes
• Increased secretion of parathyroid hormone
• Destruction of bone due to accelerated turnover
• Vitamin D related disorders
• Renal failure

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Monckebergs Sclerosis

• Degenerative and non-inflammatory disease
• of small and medium-sized muscular arteries
  becomes calcified independently of
  atherosclerosis.
• It does not involve the intimal layer of the
  artery, the lumen is kept open by the rigid
  media.
• MS is a risk factor for cardiovascular disease
  and peripheral artery obstruction

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• Glucose intolerance, aging, male gender,
  autonomic neuropathy, osteoporosis and, chronic
  renal failure.
• It commonly occurs in peripheral arteries of the
  lower limbs where it is seen as "rail tracking"
  on incidental plain radiographs

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Calciphylaxis

• Calciphylaxis ? characterized by systemic medial
  calcification of the arterioles that leads to
  ischemia and subcutaneous necrosis.
• Histologicallyi) small vessel mural
  calcification with or without endovascular
  fibrosis
• ii)extravascular
  calcification (amorphous luminal calcium)
• iii) thrombotic
  vaso-occlusion (leading to ischemic skin
  necrosis).

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• Calciphylaxis is one of several types of
  extra-osseous calcification (which also include
  intimal, medial, and valvular calcifications)
  ?occur in patients with end-stage renal disease
  (ESRD).
• Calciphylaxis most commonly occurs in patients
  with end-stage renal disease (ESRD) who are on
  hemodialysis / who have recently received a renal
  transplant .

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• Thankyou

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