Ok, here is the case this week. Sorry – another tragic one, these seem to be the ones that stick in my mind.
32 yo Japanese woman on a working holiday around Australia. She is thin, fit and well. No recent illness, travelling in Australia for a year working in the hotel industry mainly.
She presented to ED late one night with a persistent cough – dry, non-productive, irritating cough. No fever, dyspnoea, recent URTI or VTE risk of note. Seen by the senior nurse and given a course of amoxicillin with advice to see GP for follow-up. All is well.
3 weeks later – represents to ED with ongoing cough, no change with Amoxil or subsequent course of roxithromycin from GP. PNA result from GP – no significant viruses or pertussis, not Mycoplasma either. Now states she has been experiencing some exertional dyspnoea. On examination – nothing to find, chest clear, ENT all fine. Obs all normal, except for mild hypoxia on RA. ABG showed asubtle A-a gradient. The ED doc decided she needed to be admitted for a work-up in the AM.
So, next day – CXR done, not much to show – maybe some faint increased opacity in lower lung fields – reported as normal.
Spirometry was normal – no sign of obstructive or restrictive changes, decent peak flows.
Bloods showed a normal white cell count, mild anaemia and normal CRP. Only anomaly was a slightly elevated Ca++.
Quaternary survey (the Med Student went and saw the patient!): no new changes, though the student swore she could feel a single 1 cm LN in the lower jugular chain, this was ignored by yours truly….
So – being the type of guy I am, I decided to use time as a diagnostic tool and put her on some ABs. Give it 24 hours and see if she is any better. The next morning – she was definitely not better, now becoming uncomfortably hypoxic – SpO2 in the low 90s in RA, despite being well to look at, cough persisting and becoming more continuous – still no sputum. So I did what we usually do when faced with uncertainty – order a bunch of tests – a Medicare funded “fishing expedition”: repeat the bloods, ABG and see.
So all this showed the same, but the hypoxia was worse. Back at the bedside the patient was now notably SOB on sitting in bed. So we decided to open the PE can of worms – a CTPA was ordered…
Q: is there a PE
So what did the report say?
Bilateral perihilar lymphadenopathy, some reticular changes in the lung fields. Highly suspicious for sarcoidosis.
So, great – a diagnosis, made sense – young woman, not looking infectious, slight Ca bump – could be sarcoidosis – after all it is at the bottom of every Int. Med Differential Diagnosis list…
So we discussed the case with the Resp Physician in the south who said: good, send her down for a bronch etc.
However… she got more SOB, started to become tachypnoeic at rest. Oxygen applied, but still in mid 90s on 8 L/min, empirical nebs not helping. We decided to try some NIV to see if we could get her fit for transfer without intubation. The BiPAP machine helped for a while but after a few hours she became increasingly hypoxic. Not looking great. ABG showing hypoxia with low normal PCO2.
Unfortunately her respiratory failure increased and we decided to move to Resus and intubate. Relatively straightforward intubation, however her BP did crash with drugs and change to ventilator. Over the next hour, her oxygen requirements / PEEP increased and the gases got worse.
An NGT was inserted (as per usual) and surprisingly we got some frank blood up the tube – no good explanation for this could be found.
Despite our best efforts she became markedly hypoxic and eventually went into PEA, all the usual resus insued with no return of circulation.
The post-mortem showed – large ulcerated, bleeding gastric carcinoma with extensive metastasis including widespread lymphangitis carcinomatosis. And the malignant lymphadenopathy extended into the mediastinum and the supraclavicular chain.
1) Common things are common – however, common things in Japan are common in Japanese people. The rate of gastric Ca in Japan is high – 5 times that of Australia. You have to appreciate the context and background of the patient in front of you. I am sure that mild anaemia in Japan would prompt a gastroscopy ASAP, the same way PR bleeding makes us think colon Ca.
2) Sometimes the radiology report can be wrong – my quick review of the literature showed that it is really not too hard to call lymphangitis something else – eg. sarcoidosis. I am no radiologist, I rely heavily on the report for interpretation – however if what you are seeing clinically doesn’t really equate with what the report says – then you might want to keep an open mind.
3) Sometimes the Medical Student is right. I know – radical idea, but our students sometimes are so fastidious and honest that they see things that we don’t, or that we do see but explain away in our heads. Just like the emporer’s new clothes!