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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 . 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. 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 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 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