Download PICKWICKIAN SYNDROME Grand Rounds Case Protocol Team 5

PICKWICKIAN SYNDROME
Grand Rounds Case Protocol
Team 5: Abela, Caro, Cosalan, Dator, De Castro, J. Hernandez, L. Hernandez, Ishimura, Pascua
Objectives
1. To discuss a case of a patient presenting with complications of morbid obesity.
2. To understand the pathophysiology of Obesity-Hypoventilation Syndrome, also known as Pickwickian
Syndrome
3. To identify the possible complications of morbid obesity and OHS.
4. To identify public health and hospital management issues related to the patient
5. To recommend lifestyle modification techniques to prevent complications of OHS
History (Subjective Data)
Identifying Data
This is the case of FDC, a 47-year-old male, single, Filipino, Roman Catholic from Mandaluyong City admitted on
November 12, 2011 at our institution.
Informants
Patient himself and the patient’s girlfriend
Reliability: Fair (70%)
Chief Complaint
Fever
History of Present Illness
Two weeks prior to consult, the patient experienced discoloration/darkening of the foot and toenails slowly
progressing to the ankle on both feet more pronounced on the right foot. There was no associated pain or
swelling. There was no consult done and no medications taken. The patient was able to resume with his usual
daily activities without any restrictions or limitation of motion.
1 day PTA patient noted swelling and tenderness of right foot pain scale of 2/10 but claimed that he still can wear
shoes, walk and drive. No medications taken.
12 hours prior to admission, the patient developed sudden onset remittent fever with highest temperature of
40C. He self-medicated with 5 tablets of Ibuprofen/Paracetamol 200/325mg (Alaxan), 1 tablet of Paracetamol
500mg. This was also associated with body malaise and dizziness which was rotatory in character was not
aggravated by head movement and was relieved by rest.
There was no associated nausea, vomiting, abdominal pain, diarrhea, flank pain, dysuria, ear pain, ear discharge,
tinnitus and hearing loss.
Persistence of symptoms prompted patient to seek consult and subsequent admission.
Past Medical History
The patient claims to have been diagnosed with vertigo 2 years ago by their company physician. His vertigo will
usually present with tinnitus and would spontaneously resolve. He was prescribed unrecalled medications for the
vertigo on an as needed basis.
The patient has a history of Childhood Asthma. Last attack was more than 30 years ago and he is not maintained
on any medications. The patient was previously admitted at The Medical City in 2005 for Dengue Fever, nonsevere. He denies any history of hypertension, diabetes, thyroid disorders or heart/kidney/liver disease. He has no
history of Tuberculosis infection or known exposure to TB. He is not taking any maintenance medications nor has
any history of steroid use. The patient has no known allergies to food or medications.
The patient does not have any adult vaccines. Unrecalled childhood immunizations.
The patient has no known history of any previous surgeries.
Family Medical History:
The patient has a family history of hypertension, stroke and goiter on the maternal side and diabetes on
the paternal side. There is no family history of tuberculosis, asthma, kidney/heart/liver disease.
Genogram:
Personal and Social History:
The patient is single and lives with his girlfriend in Mandaluyong City. He has been working as the Area
Manager of Jollibee for more than 5 years.
The patient claims to have been a heavy eater since he was a child and has always been overweight. He
claims to be fond of three home cooked meals a day with no snacks in between. But his girlfriend says that
although he eats a “well-balanced meal”, he eats very large servings (ex. 3 cups of rice).
The patient has been living a sedentary lifestyle but claims to have started walking 3x/week for 30-45min
and occasionally plays badminton within the past month as advised by their company physician. He is not allowed
to do strenuous exercises such as basketball and jogging since his doctor claims that his knees won’t hold his
weight.
His employer is currently monitoring his weight loss as part of the Performance Management evaluation
of his company.
Patient denies any history of smoking, drinking or taking any illicit drugs.
Review of Systems
General. No significant change in weight. Excessive daytime sleepiness.
Skin. No lumps, sores or itching.
HEENT. No headache. No blurring of vision, no nose or gum bleeding, no hoarseness, no neck pain. Girlfriend
notes loud snoring at night with choking episodes.
Respiratory. No hemoptysis, no dyspnea, no wheezing
Cardiovascular. No chest pain, no palpitations, no orthopnea.
Gastrointestinal. No dysphagia, no change in bowel habits, no jaundice, no rectal bleeding
Urinary. No increased frequency in urination, no changes in color of urine, no incontinence; no nocturia or
dribbling
Genitalia. No hernias, discharge, testicular pain or masses
Musculoskeletal/Extremities. No joint pains, no tremors, muscle pain or rigidity. No varicosities, no arm or leg
pain
Psychiatric. No changes in personality. No changes in sleep pattern.
Neurologic. No drowsiness, no loss of consciousness, no numbness, no involuntary movements, no loss of
balance.
Endocrine. No heat/cold intolerance, no diaphoresis, no excessive thirst or hunger.
Physical Exam (Objective Data)
The patient was seen lying in bed, comfortable, of heavy build, well groomed, wearing a hospital gown.
He was awake, alert, coherent, cooperative, and able to respond to questions, with no signs of cardiorespiratory
distress. He appeared irritable upon interview.
Vital Signs
Blood pressure was measured at 100/70, heart rate at 84, respiratory rate at 20, temperature of 38.8°C. and Pain
Scale of 6/10
Anthropometrics
Height of 153cm, Weight of 110kg BMI of 47 kg/m2 (Obese III) Abdominal girth 116cm (45.7inches)
HEENT
Head
Normocephalic, atraumatic
Eyes
Pale palpebral conjunctiva. Anicteric sclera. No gross lesions. No ocular discharge.
Ear
No lesions, tenderness or deformity observed on the external ear and external ear canal. Intact tympanic
membrane with good cone of light. There was no aural discharge.
Nose
Symmetric ala nasi. Nasal septum midline. No congestion or discharge. No visible masses or lesions.
Anterior and posterior rhinoscopy was not done.
Mouth and Pharynx
Jaw is mobile with no limitation of motion. Oral mucosa, mouth floor and gums are moist and pink.
Hypertrophic non-hyperemic tonsils (~Grade III) with no exudates.
Neck
No visible neck mass or swelling, trachea is midline. Acanthosis nigricans on the posterior portion of the
neck. No cervical lymphadenopahies. Thyroid gland was not visible and not palpable.
Pulmonary
Equal chest expansion. No visible lesions, masses or retractions. No use of accessory muscles of respiration.
Difficulty in eliciting lung resonance.
Clear breath sounds.
No crackles, rhonchi or wheezes heard
Cardiac
Adynamic precordium. No heaves or thrills. PMI at the 5th intercostal space of the left midclavicular line
Normal cardiac rate, regular rhythm, good S1 and S2. No murmurs heard.
Abdomen
Soft, protruberant abdomen. No visible skin lesions or pulsations. No surgical scars. No abdominal striae.
Normoactive bowel sounds. Tympanitic on all quadrants.
Liver span not done.
No tenderness upon light and deep palpation of all quadrants. Liver and spleen not palpable. Negative for
fluid wave and shifting dullness.
Skin; Nails; Extremities
There was note of hyperpigmentation of the distal 1/3 of bilateral lower extremities.
Swelling, erythematous and tender (pain scale 3/10) of the right leg
No rashes, petechiae, or ecchymosis.
No clubbing, no nail deformities noted. Whitish to yellow chalk like non-pruritic lesions on bilateral 1st and
2nd toenails and yellowish chalk like lesion on top of crusted wound at the 1st interdigit right toe.
Grade I pulses on the right lower extremity; Grade II pulses on the left lower extremity
Good skin turgor with a capillary refill time of less than 2 seconds
Neurologic
The patient was awake, conscious and coherent with a GCS score of 15.
Cranial Nerves - intact
I – not tested
II, III - pupils 1-2mm, equally brisk and reactive to light
III, IV, VI - full and equal EOM movement
V sensory – 100% sensation V1, V2, V3
VII motor – no facial asymmetry
VIII – intact gross hearing
IX, X – symmetric palatal elevation and intact gag reflex
XII - tongue midline protrusion
MMT – 5/5 over all extremities. Normal posture. DTRs were not tested.
Sensory – no sensory defects
Cerebellar – normal finger to nose test.
Admitting Diagnosis
Cellulitis, right leg
r/o Chronic Venous Insufficiency
t/c Benign Paroxysmal Positional Vertigo
Obesity Type III; r/o Metabolic Syndrome
r/o Obstructive Sleep Apnea
t/c Tinea Cruris, Tinea Pedis
Course in the Wards
Upon arrival at the ER, the patient was noted to present with dizziness, body malaise and fever. Other vital
signs remained stable at this time. He was initially managed with an impression of Systemic Viral Infection and
was given Paracetamol 300mg IV, Ibuprofen, Betahistine 14mg and fluid hydration (PNSS). Initial laboratory
examinations requested showed the following results: leucocytosis with neurtrophilic predominance on CBC and
an elevated random blood glucose (205). Urinalysis and chest x-ray revealed unremarkable results. Blood culture
studies was also requested. The persistence of fever despite adequate fluid hydration and two doses of IV
Paracetamol prompted admission.
Upon arriving at the floors, the patient was seen asleep, with note of loud snoring and apnea-like episodes.
He was arousable during physical examination but would easily drift back to sleep. The patient was seen and reexamined later that day. There was persistence of fever (T 39.9C) and was now noted to be tachypneic (RR=24).
Additional physical exam findings revealed erythema, swelling and tenderness of the right leg. The patient was
started on Clindamycin (Dalacin C) 600mg IV every 8 hours with right leg elevation and Ipatropium + Salbutamol
(Combivent) nebulisation every 8 hours and as needed basis with strict aspiration precaution.
He was referred to Pulmonology service for possible Obstructive Sleep Apnea, Dermatology and Cardiology
service for possible Chronic Venous Insufficiency and Endocrinology Service for possible Metabolic Syndrome.
Additional work up done for metabolic syndrome showed an elevated HBA1c (7.28%) and lipid profile showing a
decrease in HDL levels (Cholesterol 121.20 mg/dl, HDL 39.61mg/dl, LDL 56.92, TGL 77.00) therefore ruling in
Metabolic Syndrome and Diabetes Mellitus Type 2. A liver function test was also done to check for non-alcoholic
fatty liver disease showing normal ALT levels (26 U/L).
On the night of the first hospital day, there was note of 2 episodes of desaturation to 85-87% at room air
(pulse oximeter) with persistence of tachypnea (RR 27) and fever (T 39.1). This was also accompanied by
tachycardia (HR 121). He denied any episodes of chest pain. An ABG was done which showed metabolic alkalosis
with mild hypoxemia (pH 7.467, pCO2 39.7, pO2 37.6, HCO3 28.4, BE of 5.3 and O2 sat 74.8%) with P/F ratio of
179. The patient was placed on oxygen support via nasal cannula at 2LPM. A repeat ABG was done still showing
metabolic alkalosis with respiratory alkalosis and an improvement of O2 saturation (pH 7.46, pCO2 36.7, pO2 57.3,
HCO3 26.4, BE 3.6, O2 sat 91.61%) with a P/F ratio of 286. The patient was placed on CPAP with the following
settings: Side flow of 5cm and O2 at 5lpm An ECG was also done showing sinus tachycardia (Rate 119) and nonspecific ST wave changes. Assessment was Severe Sepsis; Hypoxemia secondary to Acute Respiratory Distress
Syndrome secondary to Obesity Hypoventilation Syndrome (Pickwickian Syndrome) to r/o to Pulmonary
Embolism.
A Stat D-dimer was done due to acute progression of symptoms. This revealed a value within normal range
(1.8ug/ml) reducing the likelihood of a thrombotic event. A venous duplex scan and pulmonary CT arteriogram
were also requested for further work up. The patient was given Acetylcysteine (Fluimicil) 600mg dissolved in ½
glass of water and serum creatinine should be at normal level prior to the CT arteriogram. The patient was also
started on Enoxaparin 0.6mL SC BID.
The patient was transferred to the Intensive Care Unit for closer monitoring and further evaluation.
On the second hospital day, the patient’s first day at the Intensive Care Unit (ICU), the patient was seen
awake with persistence of fever (T 39.4C) tachypnea (RR 36) and tachycardia (HR 121) with 02 saturations
maintained at 95-97% on CPAP. There were also transient episodes of increased blood pressure to 140/90 with
spontaneous resolution. Additional pertinent physical exam findings showed continued swelling of the right leg
with erythema and hyperpigmentation of both lower extremities. There was also note of thickening of
hyperpigmented scaly plaques in the left groin area.
The CT Pulmonary Arteriogram requested revealed no evidence of pulmonary thromboembolism, nonspecific infiltrates on both lung apices, minimal bilateral pleural effusion, an enlarged thyroid lobe, right (~2 x 1.7
cm), a right hepatic cyst in the segment 8 of the right liver lobe (6.2x6.6 cm); bilateral inguinal
lymphadenopathies; and to consider cellulitis of the right thigh. The Duplex Scan of the lower extremities revealed
no evidence of acute deep vein thrombosis; deep vein reflux of the right popliteal vein and left common femoral
vein and a superficial vein valve reflux on the left greater saphenous vein. This ruled out any thromboembolic
events that may have caused the patient to go into acute respiratory distress. This also confirms the presence of
Chronic Venous Insufficiency.
Blood culture results were negative for any microbial growth. The patient was requested to undergo PPD
skin testing, AFB sputum smear and thyroid function tests to correlate with results of CT Scan. KOH smear was
also requested for the groin and right toe.
Clindamycin, Enoxaparin, Acetylcysteine and Paracetamol were continued. The patient expressed his
frustration with the management of his symptoms since he feels that his fever was not being addressed and was
feeling discomfort over wearing the CPAP which also caused restrictions in mobility.
On the third hospital day (second day in the ICU), the patient continued to have intermittent fever (T 38.3)
with stable vital signs with O2 saturation maintained at 96-97% on CPAP with setting of 5 with sideflow of 2lpm.
He denied any chest pain or dyspnea and was able to tolerate use of the CPAP. A repeat ABG was done showing
metabolic alkalosis with adequate oxygenation (pH 7.32, pCO2 39.2, pO2 58.8, HCO3 25.5, O2 sat 91%).
The patient’s right leg was still erythematous and swollen with resolution of tenderness. TSH levels were
within euthyroid range (0.56uIU/ml). IV Clindamycin and Acetylcysteine were continued and Enoxaparin was
reduced to 0.6ml SC OD with the addition of Diosmin Hesperidin (Daflon)tablet and Metformin 500mg tablet TID.
The patient was transferred back to a private room since there have been no episodes of desaturations for more
than 24hours and there are signs of resolution of infection.
On the fourth-fifth hospital day, the patient had no recurrence of fever and no difficulty of breathing. The
patient can ambulate with decreased pain (2/10) of the right leg on movement and pressure. The patient’s vital
signs remained stable with O2 saturations of 95-97% on CPAP. Upon physical examination, there was decrease in
erythema of the right leg.
A 2D Echo was requested to assess cardiac function for further work up due to possible complications of
Metabolic Syndrome. Metformin was placed on hold and a request for Fasting Blood Glucose was done with CBG
monitoring three times a day. CBG results ranged from 90-110 with no oral hypoglycemic taken.
KOH preparation done on the right toe, groin area and subungal deposits were negative for fungal
elements. Sputum AFB smear was negative however the PPD skin test on the right forearm showed an induration
of 13mm with erythema after 48 hours, classifying the patient to have Latent Pulmonary Tuberculosis.
On the sixth to seventh hospital day, there was no recurrence of fever and no episodes of desaturation.
There was note of significant improvement of discoloration and swelling of the right leg and the patient was able
to ambulate freely in his room with no pain. Physical examination revealed stable vital signs with O2 saturation at
96% at room air and further resolution of the cellulitis. Repeat CBC and liver function test were done. Clindamycin
was shifted to oral form at 300mg/capsule to take 2 capsules every 6 hours due to difficulty in re-inserting an IV
line. Topical antifungals were also started for the nail, groin and toes.
With the continuous resolution of symptoms, that patient’s condition improved and was subsequently
discharged with the following home medications
1. Metformin 500mg/tab, 1 tab after breakfast and 1 tab after dinner; # 60
2. Clindamycin 400mg /cap, 2 cap every 6 hours for 1 week; # 14
3. Combivent nebulization, nebulize every 8 hours with ½ neb and 1 mL PNSS as needed for dyspnea
4. Amorolfine (Losetar) nailpolish – apply to affected nails (for toe nails)
5. Amorolfine (Losetar) cream – apply to soles and in between toes once a day at bedtime (for Tinea
plantaris)
6. Clotrimazole + Bethametazone (Clotrazone) cream – apply to inguinal area 2 x a day for 2 weeks (for
tinea cruris)
7. Cetaphil moisturizing lotion – apply moisturizing lotion to dry areas of both legs after bathing daily
(for dryness of both legs)
The patient was advised to acquire a CPAP for home use and was advised to undergo nutrition and weight
management. He was also advised to follow up after 2 weeks with a 2-hour OGTT result and Thyroid Ultrasound
and to undergo polysomnography.
Final Diagnosis
Severe Sepsis secondary to Cellulitis of the right leg
Acute Respiratory Failure (Type I) secondary to Obesity Hypoventilation Syndrome (Pickwickian Syndrome)
Metabolic Syndrome (Diabetes Mellitus Type II, Obesity Type III)
Chronic Venous Insufficiency
Latent Tuberculosis
Subungal Tinealis, Tinea Plantaris, Tinea Cruris
t/c Benign Paroxysmal Positional Vertigo
t/c Obstructive Sleep Apnea