About This Presentation

1
About This Presentation

• This is the PowerPoint from the video, it
  contains
• The definition and rules of the Clinical
  Pathologic Case (CPC) competition
• A sample CPC presentation

2
About This Presentation

• Please note
• The notes section contains written text of the
  video dialogue for you to follow during this
  presentation

3
The CPC CompetitionExplained

• John C. Southall, M.D.
• Mercy Hospital, Maine, USA

4
What to Expect

• You will receive case 4 weeks in advance
• History and Physical
• Other pertinent facts
• Ancillary tests
• May include Labs, ECGs, X-rays

5
What to Do

• Create a 20 minutes PowerPoint presentation
• Presentations must be in English
• Non-native English speakers allowed 25 minutes

6
Judging

• The quality of the differential diagnosis
• Thought process of achieving final diagnosis
• Presentation skills
• Presentation impact
• Adherence to time limits
• Arriving at the correct diagnosis is a bonus but
  not necessary to win

7
Questions?

• Email me at
• southallj_at_mercyme.com

(John C. Southall, M.D.)
8
(No Transcript)
9
Sample Case1st Presented San Francisco,
California

• Moderator
• Dr. Amanda Young, M.D.

10
Title A 34 Year-old Woman with Visual Loss and
Eye Pain

• Chief Complaint
• 34 year-old Caucasian woman with two days of
  decreased vision in her right eye and throbbing
  pain behind her eye

11
History of Present Illness

• For several weeks she states that she has not
  felt quite right. 3 days ago she was seen in
  the Emergency Department of a local community
  hospital. The patient was told that her physical
  exam including pelvic exam were normal and some
  lab tests were sent. She was discharged and told
  to follow up with her primary medical doctor.
  She sees a doctor at a community health center,
  and has an appointment for next week.

12
History of Present Illness

• 2 days ago she noticed that she couldnt see the
  bottom half of the world from her right eye.
  This came on gradually, but has not resolved and
  continues today. Yesterday she developed pain
  behind her right eye. The pain is worse with
  coughing or straining, but doesnt change with
  movement of her eyes. She denies any symptoms in
  her left eye.

13
Past History

• PMH Depression, GERD, Bulimia
• G0P0
• No eyeglasses or contacts
• PSH Splenectomy 6 months prior for ruptured
  spleen sustained in a car accident. She required
  blood transfusions during her hospitalization.
• Meds Citalopram, Pantoprazole, Birth Control
  Pills, MVI, FeS04
• Allergies None
• FH Mother had breast cancer, Father died of a
  heart attack. No blindness or glaucoma in her
  family.

14
Social History

• Rhode Island native, never lived out of state
• No recent travel out of Northeastern U.S.
• Unemployed, currently lives at residential drug
  treatment center
• Uses crack cocaine and tobacco
• Has been in prison once 3 years prior
• Claims one sexual partner currently
• Negative H.I.V. test 3 years prior
• Denies having had or been exposed to TB

15
Review of Systems

• Positive for
• 10 lb weight loss x 2 weeks
• Fatigue, dizziness, insomnia, headache x 1 month
• Hair loss x 2 weeks
• LMP 3 weeks ago

• Negative for
• Trauma
• Fevers, night sweats
• Back pain
• Cough, chest pain, shortness of breath
• Abdominal pain, dysuria, discharge, dyspareunia
• Focal weakness or sensory complaints

16
Physical Exam

• T 98.8, 110/66, P 76, RR 16, SpO2 97
• Young woman, in no distress, holding R eye

17
Eye

• Visual Acuity L 20/20, R 20/40
• Pupils Equal, Round, Reactive to light and
  accommodation
• EOM Full range of motion, No INO
• Conjunctiva clear
• Lid, Iris, Lens all appear normal

• Normal fluoroscein exam
• Anterior Compartment L trace cells, R 1 cells
• Intra-ocular Pressure L 14, R 10
• Fundoscopy performed with PanOpthalmic scope
• Visual deficit as follows

18
Fundoscopy
Right Eye
Left Eye
19
Eye

• Visual Acuity L 20/20, R 20/40
• Pupils Equal, Round, Reactive to light and
  accommodation
• EOM Full range of motion, No INO
• Conjunctiva clear
• Lid, Iris, Lens all appear normal

• Normal fluoroscein exam
• Anterior Compartment L trace cells, R 1 cells
• Intra-ocular Pressure L 14, R 10
• Fundoscopy performed with PanOpthalmic scope
• Visual deficit as follows

20
Right Quadrantopsia
Right Eye
Left Eye
21
Physical Exam

• Neck Anterior cervical lymphadenopathy, thyroid
  normal size, non-tender
• Cardiac Normal S1 and S2, no murmur, normal
  distal pulses, no peripheral edema.
• Lungs Clear bilaterally. Bilateral axillary
  lymphadenopathy
• Abdomen soft, non-tender, no hepatomegaly,
  shotty inguinal lymphadenopathy bilaterally, no
  CVA tenderness.

22
Physical Exam

• Pelvic
• Normal external exam
• No vaginal bleeding
• No cervical motion tenderness, non-tender uterus
  and adnexae
• Rectal Occult blood negative
• Skin
• Irregular hair loss on scalp, no scabbing
• Several irregular pigmented lesions on back

23
Labs

• CBC and Chemistries unremarkable
• ESR 48
• LFTs
• Alk phos 64
• AST/ALT 126/249
• PT normal at 12.2

24
Lumbar Puncture

• Tube 1
• 15 WBCs
• 9 RBCs

• Tube 4
• 20 WBCs
• 1 RBC
• Protein 32
• Glucose 57
• Colorless

25
EKG
26
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27
Head CT Non Contrast
Read as normal non-contrast head
28
Contestant/Discussant

• Dr. John Southall, M.D.
• Maine Medical Center, USA

29
A 34 Year-old Woman with Visual Loss and Eye
Pain

• Generating a differential diagnosis shouldnt be
  a problem!

30
Problem List

• Eye Pain
• Visual loss
• Malaised x 1 month
• Depression
• GERD
• Bulemia
• Splenectomy
• Blood transfusions
• Daily meds
• Crack cocaine
• Hx incarceration
• 10 lb weight loss over 2 weeks

• Hair loss over 2 weeks
• Cervical, axillary, inguinal Lymphadenopathy
• Ant comp 1 RBCs
• Abnormal fundoscopy
• Field cut
• Irregular hair loss
• Irregular pigmented skin lesions
• ESR 48
• AST/ALT elevated
• CSF WBCs
• EKG/CXR/CTH

31
Real World

• CC Visual loss
• Painful vs. Painless?
• Ptn Painful visual loss
• Instantly generates a list of emergent conditions

32
Real World DDx Eye Pain

• Foreign body
• Herpes zoster
• Trauma
• Conjunctivitis
• Iritis
• Iridocyclitis
• Uveitis
• Blepharitis
• Ingrown lashes
• Orbital or periorbital cellulitis/abscess

• Sinusitis
• Glaucoma
• Inflammation of lacrimal gland
• Tic douloureux
• Cerebral aneurysm
• Cerebral neoplasm
• Entropion
• Retrobulbar/optic neuritis
• Ultraviolet keratitis
• Dry eyes (ie lasik)
• Irritation or inflammation from eye drops, dust,
  cosmetics

33
Real World

• Differential diagnosis narrowed
• By history
• By physical exam
• By diagnostics

34
Real World

• Differential diagnosis narrowed
• By history
• By physical exam
• By diagnostics

35
Real World

• Differential diagnosis narrowed
• By history
• By physical exam
• By diagnostics

36
Real World Easy Rule Outs

• Foreign body
• Herpes zoster
• Trauma
• Conjunctivitis
• Iridocyclitis
• Blepharitis
• Ingrown lashes
• Glaucoma

• Inflammation of lacrimal gland
• Tic douloureux
• Entropion
• Ultraviolet keratitis
• Dry eyes (ie lasik)
• Irritation or inflammation from eye drops, dust,
  cosmetics

37
Real World

• Rule Outs Requiring Basic Diagnostics
• Orbital or retro-orbital cellulitis
• Deep abscess
• Sinusitis
• Cerebral neoplasm

38
Real World

• Can Not Rule Out
• Uveitis
• Cerebral aneurysm/dissection
• Optic neuritis or neuropathy

39
This Is Not The Real World

• This is California!

40
Problem List

• Eye Pain
• Visual loss
• Malaised x 1 month
• Depression
• GERD
• Bulemia
• Splenectomy
• Blood transfusions
• Daily meds
• Crack cocaine
• Hx incarceration
• 10 lb weight loss over 2 weeks

• Hair loss over 2 weeks
• Cervical, axillary, inguinal Lymphadenopathy
• Ant comp 1 RBCs
• Abnormal fundoscopy
• Field cut
• Irregular hair loss
• Irregular pigmented skin lesions
• ESR 48
• AST/ALT elevated
• CSF WBCs
• EKG/CXR/CTH

41
Specific vs. Nonspecific

• Specific
• Visual loss
• Specific field cut
• Retinal injury
• Abnormal fundoscopy
• Eye pain

• Nonspecific
• Supporting data or
• Red Herring?

42
Visual Loss

• Specific Field Cut (thanks!)
• This must narrow the differential

43
Monocular Quadrantopsia

• Medline through 1969 yields nothing

44
Monocular Quadrantopsia

• Medline through 1969 yields nothing
• search yields nothing
• ever seen that?
• Back to the basics!

45
Field Cut Basics

• Monocular vs. Binocular?

Our patient
Right Eye
Left Eye
Monocular!
46

• Place the Lesion!

Our patient
Right Eye
Left Eye
47
(No Transcript)
48
Acquired Optic Neuropathy

• By definition

49
Acquired Optic Neuropathy

• Compressive
• Infiltrative
• Inflammatory
• Vascular
• Toxic/Nutritional
• Traumatic
• Mechanical

50
Immediate Rule Out

• Increased intracranial pressure
• Glaucoma
• Nutritional and toxic optic neuropathy
• Traumatic

51
Acquired Optic Neuropathy

• Optic neuritis
• Ischemic optic neuropathy
• Optic nerve compression
• Inflammatory optic neuropathy

52
Acquired Optic Neuropathy

• Optic neuritis
• Ischemic optic neuropathy
• Optic nerve compression
• Inflammatory optic neuropathy

53
Optic Neuritis
Acute monocular loss of vision caused by focal
demyelination of the optic nerve

• Pros
• Acute monocular vision loss

• Cons

54
Optic Neuritis
Acute monocular loss of vision caused by focal
demyelination of the optic nerve

• Pros
• Acute monocular vision loss
• Age 15 to 45 years

• Cons

55
Optic Neuritis
Acute monocular loss of vision caused by focal
demyelination of the optic nerve

• Pros
• Acute monocular vision loss
• Age 15 to 45 years
• Painful

• Cons

56
Optic Neuritis
Acute monocular loss of vision caused by focal
demyelination of the optic nerve

• Pros
• Acute monocular vision loss
• Age 15 to 45 years
• Painful

• Cons
• Afferent pupillary defect not present

57
Optic Neuritis
Acute monocular loss of vision caused by focal
demyelination of the optic nerve

• Pros
• Acute monocular vision loss
• Age 15 to 45 years
• Painful

• Cons
• Afferent pupillary defect not present
• No pain with EOEM

58
Acquired Optic Neuropathy

• Optic neuritis
• Ischemic optic neuropathy
• Optic nerve compression
• Inflammatory optic neuropathy

59
Ischemic Optic Neuropathy

• Not embolic
• Central retinal artery occlusion
• Branch retinal artery occlusion

CRAO
BRAO
60
Ischemic Optic Neuropathy

• Generalized decrease of blood flow to the optic
  nerve
• Most common cause of optic neuropathy worldwide
• Non-arteritic
• Artertic

61
Arteritic ION (Temporal Arteritis)

• Pros
• Secondary Sx
• Weight loss
• Malaise
• Headache
• Scalp tenderness (hair loss)

62
Arteritic ION (Temporal Arteritis)
Temporal Arteritis

• Pros
• Weight loss, malaise, headache
• Optic disc has pallor and swelling

Our Patient
63
Arteritic ION (Temporal Arteritis)

• Pros
• Weight loss, malaise, headache
• Optic disc has pallor and swelling
• Elevated ESR

• ESR 48

64
Arteritic ION (Temporal Arteritis)

• Pros
• Weight loss, malaise, headache
• Optic disc has pallor and swelling
• Elevated ESR

• Cons
• Extremely rare younger than 50 years of age

34 years old
65
Arteritic ION (Temporal Arteritis)

• Pros
• Weight loss, malaise, headache
• Optic disc has pallor and swelling
• Elevated ESR

• Cons
• Patient too young
• Large afferent pupillary defect

66
Arteritic ION (Temporal Arteritis)

• Pros
• Weight loss, malaise, headache
• Optic disc has pallor and swelling
• Elevated ESR

• Cons
• Patient too young
• No afferent pupillary defect
• Painless
• visual loss

67
Acquired Optic Neuropathy

• Optic neuritis
• Ischemic optic neuropathy
• Optic nerve compression
• Inflammatory optic neuropathy

68
Optic Nerve Compression

• Pros
• Occurs at any age
• Tumor, aneurysm, sphenoid sinusitis, blunt trauma

• Cons

69
Optic Nerve Compression

• Pros
• Occurs at any age
• Prechiasmal disorder

• Cons

70
Optic Nerve Compression

• Pros
• Occurs at any age
• Prechiasmal disorder

• Cons
• Compressive syndromes tend to involve other
  cranial nerves

71
Optic Nerve Compression

• Pros
• Occurs at any age
• Prechiasmal disorder

• Cons
• No other cranial nerve involvement
• No afferent pupillary defect

72
Optic Nerve CompressionThe AnatomyWillis!
73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76
Ophthalmic Artery
77
Optic Nerve CompressionOphthalmic Artery
Aneurysm

• Pros
• Adequately eloquently explains chief complaint

• Cons
• Does not explain ancillary data
• No other cranial nerve involvement
• No afferent pupillary defect

78
Acquired Optic Neuropathy

• Optic neuritis
• Ischemic optic neuropathy
• Optic nerve compression
• Inflammatory optic neuropathy

79
Inflammatory Optic Neuropathy

• Non-Infectious vs. Infectious

80
Inflammatory Optic Neuropathy

• Non-Infectious vs. Infectious

81
Sarcoidosis

• Multi-system granulomatous disorder
• Up to 50 ocular involvement
• Ocular sarcoidosis
• Occurs early in the course of the disease
• fever, fatigue, weight loss, and malaise

82
Ocular Sarcoidosis

• Pros
• Anterior uveitis common
• Our patient had 1 cells

83
Ocular Sarcoidosis

• Pros
• Posterior disease common
• Vitritis, uveitis, retinal vasculitis

Our Patient
84
Ocular Sarcoidosis
Sarcoid

• Pros
• Anterior/posterior segment manifestations
• Punched-out choroidoretinal lesions

Our Patient
85
Ocular Sarcoidosis

• Pros
• Anterior/posterior segment manifestations
• Punched-out choroidoretinal lesions
• Skin lesions are found in 35 of the patients

86
Ocular Sarcoidosis

• Pros
• Anterior/posterior segment manifestations
• Punched-out choroidoretinal lesions
• Skin lesions
• Generalized lymphadenopathy

87
Ocular Sarcoidosis

• Pros
• Anterior/posterior segment manifestations
• Punched-out choroidoretinal lesions
• Skin lesions
• Generalized lymphadenopathy
• Hepatic involvement

88
Ocular Sarcoidosis

• Pros
• Anterior/posterior segment manifestations
• Punched-out choroidoretinal lesions
• Skin lesions
• Generalized lymphadenopathy
• Hepatic involvement
• CSF pleocytosis

89
Ocular Sarcoidosis

• Cons
• Conjunctiva usually involved (70)

90
Ocular Sarcoidosis

• Cons
• No conjunctival involvement
• Typical skin lesions
• Dissimilar to patients

91
Ocular Sarcoidosis

• Cons
• No conjunctival involvement
• Typical skin lesions
• Dissimilar to patients
• Lung is the most commonly affected organ

92
Ocular Sarcoidosis
Our Patient
Sarcoidosis stage IV
93
Ocular Sarcoidosis

• Pros
• Constitutional Sx
• Anterior uveitis
• Posterior uveitis
• Fundoscopy
• Skin lesions
• Generalized lymphadenopathy
• Hepatic involvement
• CSF pleocytosis

• Cons
• No conjunctival involvement
• Skin lesions atypical
• No lung involvement
• Does not explain
• Lymphadenopathy without hilar involvement
• Hair loss

94
Inflammatory Optic Neuropathy

• Non-Infectious vs. Infectious

95
(No Transcript)
96
From Breviary of Helth, 1547
it maye come by syttenge on a draught or sege
where as a pocky person did lately syt, it may
come by drynkynge oft with a pocky person, but
specially it is taken when one pocky person doth
synne in lechery the one with another
97
Syphilis?

• Henry VIII of England
• Ivan the Terrible
• Francis I of France
• Napoleon Bonaparte
• Ludwig von Beethoven
• Lord Randolph Churchill
• Franz Schubert

98
(No Transcript)
99
Syphilis

• Treponema pallidum
• Characterized by lipid outer surface with paucity
  of antigenic proteins

100
Secondary Syphilis

• Our Patient
• Irregular rash on back

• Secondary Syphilis
• Irregular rash
• 90 of patients
• Macular
• Maculopapular
• Papular
• Pustular

101
Secondary Syphilis

• Our Patient
• Generalized lymphadenopathy
• Anterior cervical
• Bilateral axillary
• Bilateral shotty inguinal

• Secondary Syphilis
• Generalized lymphadenopathy
• 90 of patients

102
Secondary Syphilis

• Our Patient
• Consitutional Sx
• Two weeks
• Malaise, headache, insomnia, anorexia,
• 10 pound weight loss

• Secondary Syphilis
• Consitutional Sx
• Malaise, headache, anorexia, weight loss
• 70 of patients

103
Secondary Syphilis

• Our Patient
• Hair loss
• Two weeks
• Irregular

• Secondary Syphilis
• Irregular hair loss typical

104
Secondary Syphilis

• Our Patient
• Elevated LFTs

• Secondary Syphilis
• Hepatic, renal, intestinal involvement all
  described

105
Secondary Syphilis

• Our Patient
• Two pelvic exams
• Normal

• Secondary Syphilis
• Pelvic exam normal
• 80 of the time

106
A 34 Year-old Woman with Visual Loss and Eye
Pain

• What about the chief complaint?

107
Ocular Syphilis

• One to ten percent of syphilis cases
• An uncommon illness presenting commonly?

108
Ocular Syphilis
109
Ocular Syphilis

• Anterior Uveitis
• Occurs during secondary syphilis
• 56 unilateral

• Our Patient
• Unilateral anterior uveitis
• 1 cells OD
• No cells OS

110
Posterior Uveitis

• 40 of ocular syphilis
• Hallmark painful visual loss

111
Syphilitic Uveitis/Chorioretinitis
112
Our Patient
113
Ocular SyphilisNeurosyphilis by Definition

• Ocular Syphilis
• CSF pleocytosis is the classic finding

• Our Patient
• CSF Tube 4
• 20 WBCs
• 1 RBC

114
Ocular Syphilis?

• Irregular rash on back

115
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy

116
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia

117
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss

118
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

119
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs

120
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis

121
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis
• Anterior uveitis

122
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis
• Anterior uveitis
• Posterior uveitis

123
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis
• Anterior uveitis
• Posterior uveitis
• Painful visual loss

124
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis
• Anterior uveitis
• Posterior uveitis
• Painful visual loss
• Irregular monocular field cut

125
Ocular Syphilis

• Irregular rash on back
• Generalized lymphadenopathy
• Malaise, headache, insomnia, anorexia
• 10 pound weight loss
• Irregular hair loss

• Elevated LFTs
• CSF pleocytosis
• Anterior uveitis
• Posterior uveitis
• Painful visual loss
• Irregular monocular field cut

Browning DJ - Ophthalmology - 01-NOV-2000
107(11) 2015-23
126
The Answer

• Ocular Syphilis

127
My Predictions

• Diagnostic test?
• Blood/CSF
• RPR/VDRL/FTA-ABS/MHA-TP
• HIV testing
• 41 chance of being HIV()
• Treated per neurosyphilis protocols
• IV penicillin G
• 12 to 24 million units qd X 6-21 days

128
Our Patients Ocular Future?

• 85 chance of return to near normal vision

Our Patient
Normal
129
Thank You for This Opportunity
130

• Moderator
• Dr. Amanda Young

131
The Final Diagnosis

• Ocular Syphilis

132
The Final Diagnosis

• Diagnostic test () VDRL
• Clinical course
• Two weeks of IV penicillin
• Outcome
• Almost complete recovery at 6 month follow up

133
CPC Mediterranean Emergency Medicine Congress

• Space is very limited
• Please express interest early

134
Questions Interest

• southallj_at_mercyme.com

John C. Southall, M.D.
Mercy Hospital, Portland Maine, USA Department of
Emergency Medicine