Discussant: Dr. K. Persley
Resident presenter: Dr. S. Royappa
CC: Shortness of Breath, Abdominal Pain and Distention
HPI:
Pt is a 51 year old white female who presents to PHD with a one month history of abdominal pain and distention and shortness of breath for 1 week. Two years ago, about one month after a vaginal hysterectomy she noted progressive bilateral pedal edema. Her OB/GYN prescribed furosemide with good results for 1 - 2 months. However, the edema progressed and became refractory.
To further evaluate the edema, an echocardiogram and lower extremity doppler were performed and were negative. Renal ultrasound, BUN, Creatinine, IVP, 24-hour urine, and UA were also normal.
About one year into her workup she was found to be hypothyroid and was put on levothyroxine, but her edema persisted. She was found to be hypoalbuminemic, lymphopenic, and a stool study showed an elevated alpha-1 antitrypsin level to 10 times normal level.
A CT on 10/21/02 showed diffuse enlargement and soft tissue infiltrate involving the small bowel mesentery and parapancreatic tissue with swollen nodes. She then had a CT guided biopsy of the pancreas and mesenteric root that showed benign tissue with rare lymphoid aggregates. A capsule endoscopy done on 10/18/02 revealed a proximal segment of lymphangiectasia in the jejunum beyond which the small intestine appeared normal. On 11/1/02, she had endoscopic ultrasound that showed a prominent thoracic duct but otherwise was normal. On 11/4/02, she had small bowel resection of about 30-40 cm of jejunum at Scott and White which showed lymphangiectasia that was prominent, diffuse, involving the lamina propria at the tips of the villi, submucosa, and especially the external surface. There were no malignant cells found in the resected bowel specimen.
The patient did well post-op until about 11/15 when she started to note abdominal pain, fullness, and distention. She also noted a 10 lb weight gain over 1-2 weeks. Her symptoms continued to progress until she presented to PHD on 12/6/02.
PMHx:
PSurg:
Meds:
FH: Father - hypertension and prostate cancer Mother - diabetes mellitus,
Crohn's Disease
SH: She is married and lives in McKinney with her husband. She works as a real estate broker. She has a 23 year old son in good health. She denies tobacco, alcohol , and drugs.
ROS: Otherwise unremarkable
PE:
Vitals: Temperature - Afebrile Pulse-80 BP-131/76 R-20 Gen: awake/alert/oriented/no acute distress
HEENT: Pupils equal round reactive to light, extra-ocular muscles intact, Oropharynx clear, moist membranes
Neck: Supple. No lymphadenopathy, jugular/venous distention, or bruits
CVS: regular rate and rhythm , No murmurs, gallops, or rubs
LUNGS: decreased breath sounds at bases right>left; otherwise clear to auscultation bilaterally ABD: Distended and tense, diffusely mild tenderness to palpation, bowel sounds in all 4 quadrants with a well healed surgical scar in mid-line. No heptosplenomegaly. 2x2 cm subcostal firm moveable subcutaneous mass in right abdominal wall area. EXT: 2+ pitting edema to mid calf bilaterally. No clubbing or cyanosis NEURO: Non-focal. CN II - XII grossly intact
SKIN: No rashes
CXR: Bilateral pleural effusions
EKG : Normal sinus rhythm. No acute changes
LABS:
CBC: HGB 13.0 HCT 39.0 WBC 5.0 (neut 88, mono 8, eos 2, lymphs 2) PLT 418
CHEM: NA 138 K 3.3 Cl 109 C02 25 Anion Gap 3 BUN 11 Cr 0.7 Ca 7.5
LFT's: T.P. 3.8 Alb 1.6 Glob 2.2 A1kP 97 GGT 30 AST 10 ALT 24 TB <0.2 PT 13.2 INR 1.1 PTT 32 Triglycerides 428
TFT's: TSH 2.11 (Normal 0.49 - 4.67) T3 2.37 (Normal 1.45 - 3.48) T4 1.35 (Normal 0.71 - 1.85)
UA: Color - yellow App - clear S.G - 1.030 pH - 6.0 Glucose - neg Protein - neg Blood - Neg Ketones - >80 Nitrite - neg Bili - neg Urobili - 0.2 Leuko - neg WBC - 3 Epi - 6 Calcium Oxalate - rare
PLEURAL FLUID: Color - Milky Appearance - Turbid T. Protein - <1.0 Glucose - 104 Album - <0.6 LDH - 196 RBC - 220 WBC - 240 (Lymph - 81 Segs - 4 Mono - 15)
ASCITIC FLUID: Color - Milky Appearance - Turbid T.Protein - 1.56 g/dl Glucose - 100 Amylase - <30 Album - <0.6 LDH - 237 Lipase - 141 RBC - 127 WBC - 75 (Lymph - 46 Segs 26 Mono - 28)
TUMOR MARKERS: CEA <0.5; CA 125 1477 (Normal < 35) CA19-9 7 (Normal 0-37)
PET SCAN:
A diagnostic procedure was performed and a diagnosis was established.