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EMERGENCY MEDICINE
Liverpool Hospital
The Weekly Probe
10th September 2013
Volume 16 Issue 26
THIS WEEK
Last Week’s case - Vogt-Koyanagi-Harada Syndrome
DVT & Cellulitis
Pleural Effusions & the CXR
Next week’s case
Joke / Quote of the Week
The Week Ahead
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LAST WEEK’S CASE - Vogt-Koyanagi-Harada Syndrome
A 35yo Vietnamese hearing aid technician (ie good eye sight) presented with 4 weeks of a
progressive illness. Initial viral symptoms with myalgias and lethargy followed by generalised
headaches, red eyes followed by blurring of his vision. CT head normal- treated as viral illness.
However progressive headaches and visual loss brings him back to hospital.
On examination – afebrile, normotensive – GCS 15 - only able to see light / dark bilaterally – no other
focal neuro signs – no meningism. Fundi examination showed bilaterally swollen disks ?
papilloedema. CT head and venogram both normal. LP shows elevated CSF 29cm with 128 monos –
no RBC with elevated protein. What’s going on?
He was investigated by neurology and opthal teams with normal PET, MRI, autoimmune and
infectious workup including TB. With a provisional diagnosis of Vogt-Koyanagi-Harada Syndrome, he
was treated with high dose steroids with improvement in his visual acuity over the following month.
What is this? I’d never heard of this one before but VKH is presumably a multisystem autoimmune
disease that is manifested by bilateral posterior uveitis with characteristic fluid accumulation beneath
the retina, leading to retinal elevation and detachment. It often presents as a panuveitis.
Patients may also develop vitiligo, poliosis (loss of
colour from a patch of hair), sterile meningitis (explaining his CSF abnormalities), alopecia, and eighth
cranial nerve disease.
Who? esp 20- 50 yo – less common in Caucasians
As described by Nguyen “Identify and Treat Vogt-Koyanagi-Harada Syndrome”
(http://www.aao.org/publications/eyenet/200507/pearls.cfm) there are a number of stages:
Stage 1: Prodromal. This stage, also called the meningeal stage, lasts for a few days to a few weeks
and often mimics a viral infection. Patients present with fever and neurologic features, including
meningeal involvement (headache, confusion, neck stiffness), encephalopathy (convulsions, paresis,
aphasia), focal neurologic signs (cranial nerve palsies, hemiparesis, optic neuritis), auditory
symptoms (tinnitus, vertigo, hearing loss) and CSF lymphocytosis.
Stage 2: Acute uveitic. The second stage occurs within three to five days of the prodromal stage
and lasts for several weeks. Patients experience acute ocular pain and red eyes associated with
bilateral blurring of vision secondary to uveitis, then choroiditis with disc hyperaemia or oedema +/retinal detachment. A hallmark finding is multifocal retinal detachments.Eventually the inflammation
extends into the anterior segment.
Stage 3: Convalescent. a few months later, and may last months or years with vitiligo, alopecia and
poliosis.
Stage 4: Chronic recurrent. ~ 52 % recur within the 6 months- especially anterior symptoms
Treatment- steroids +/- other immunosuppressive agents such as methotrexate.
PS a reminder on the anatomy / pathological location.
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Anterior uveitis , also known as iridocyclitis and iritis, is the inflammation of the iris and anterior
chamber- presents with scleral injection, visual change, photophobia, eye pain, floaters,
headaches
Intermediate uveitis, also known as pars planitis, consists of vitritis
Posterior uveitis or chorioretinitis is the inflammation of the retina and choroid.- Presents with
floaters, vision change or photopsia or seeing flashing lights
Pan-uveitis is the inflammation of all the layers of the uvea.
Cellulitis + DVT ?
Lower limb cellulitis and deep vein thrombosis have common clinical features and often patients with
cellulitis undergo investigation for concurrent DVT. How common is it to have both diseases
coincidentally? Can we use Well’s criteria?
In the study by Maze et. titled “Prevalence of Concurrent Deep Vein Thrombosis in Patients With
Lower Limb Cellulitis A Prospective Cohort Study” (BMC Infect Dis. 2013;13(141)) patients admitted
with lower limb cellulitis were prospectively risk stratified for DVT using the Wells criteria followed by
investigation with D-dimer and US of the ipsilateral femoral veins. Diagnoses of contralateral DVT or
pulmonary embolism during admission were recorded.
Results 200 patients assessed for DVT. 20% of subjects were high risk by Wells criteria. D-dimer was
elevated in 74% and 79% underwent US of the affected leg. Ipsilateral DVT was found in 1 patient
(0.5%) and non-ipsilateral VTE in a further 2 (1%).
Conclusions Deep vein thrombosis rarely occurs concurrently with lower limb cellulitis. The Wells
score substantially overestimates the likelihood of DVT due to an overlap of clinical signs.
Investigation for DVT in patients with cellulitis is likely to yield few diagnoses and is not warranted in
the absence of a hypercoaguable state.
Refs http://www.researchreview.com.au/subscription.cfm
Pleural Effusions on CXR
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Pleural effusion radiographic findings on chest radiographs. Sequence of accumulation is
subpulmonic > posterior angle > lateral angle.
Subpulmonic pleural effusion (ie between the diaphragm and the lung base): May be seen
when there is previously established pulmonary disease, but can also be encountered in
normal lungs.Flattening and elevation of hemi diaphragm, lateral shift of diaphragm apex (see
picture below), separation of gastric bubble from diaphragm (< 1.5 cm). On lateral, diaphragm
flat anteriorly and sharply descends at oblique fissure. They are more common on the right
side.
Editor: Peter Wyllie
(Note this is not true elevation of diaphragm but pleural fluid collection between lung base and
diaphragm
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Posterior costophrenic sulcus: (on lateral view only) blunting of the posterior costophrenic
sulcus, average quantity needed to blunt: 50 mL.
Lateral costophrenic sulcus: (on anterior view only) blunting of the lateral costophrenic
sulcus, average quantity needed to blunt: 200 mL.
Mediastinal shift away from the effusion more than 1000 mL.
Best imaging: lateral decubitus, will detect as small as 10 mL of fluid, defines a freely flowing
effusion.
In most cases, effusions due to congestive heart failure, especially when bilateral do not
require thoracentesis
Refs: www.auntminnie.com , http://radiopaedia.org/
QUOTE OF THE WEEK
Please forward any funny and litigious quotes you may hear on the floor (happy to publish names if
you want)
THE WEEK AHEAD
Tuesdays - 11.30-2.30 Intern teaching -Thomas & Rachel Moore
Wednesday
0800-0900 Critical Care Journal Club. ICU Conf Room / 12.30-1.30 Resident MO in
Thomas & Rachel Moore
Thursday 0730-0800 Trauma Audit. Education Centre / 0800-0830 MET Review Education centre /
1300-1400 Medical Grand Rounds. Auditorium.
Editor: Peter Wyllie