Quick Thinking Part 3

April 13, 2007

Bellevue RoundsWelcome to Quick Thinking. A case is presented in short sections to a faculty expert who will comment on their approach to the patient as the case unfolds. These posts will focus on determining the initial differential diagnoses and diagnostic workups of complicated patient presentations.

Part 1 can be found here.  Part 2 can be found here.

Part 3 Presented by Elizabeth Ross, PGY-3:

WBC–5.0  N63, L26, M10
Hgb-11, HCT-30, Plts 193

Na 128, K 3.6, Cl 95, CO2 23, BUN/creat 15/1.1
ast 46, alt 39,alk phos 118, bili 1.6/0.6, pro/alb 7.8/3.7
Coags wnl

ESR 62
cortisol wnl
TSH 0.16 (low), FT4  0.71
LH < 0.07 (low), FSH 2.7 (wnl), testosterone wnl
Urine Osm 271
HIV neg
Cryptococcal Ag: neg
ACE levels wnl
LDH, hcg, cea, ca 19-9 were wnl
PPD neg
Blood Cultures: several sets no growth

Brain MRI: complex suprasellar mass (approx 2 cm x 1.5 cm x 1 cm) involving bilateral optic chiasms, pituitary infundibulum and hypothalamus.  Also with leptomeningeal lesions involving the right 5th cranial nerve, internal auditory canals, and medulla and cervical cord.

An LP was performed which showed 10 WBC, 95% lymphs, glucose 27, protein 539

Abd CT (with contrast): multiple 12 mm hepatic lesions, splenomegaly (14cm), periportal/peripancreatic LAN, circumferential thickening of sigmoid.
Chest CT (with contrast): Mild, non-specific, diffuse LAN – mediastinal, subcarinal and hilar.

Commentary: Mitchell Charap, MD Abraham Sunshine Associate Professor of Medicine

The patient’s HIV status is important in that it makes toxoplasmosis and cryptococcosis less likely The laboratory data suggest a neoplastic, infectious or inflammatory process that is systemic in nature. Within the CNS there is involvement of the brain and leptomeninges. These findings along with the LP (mononuclear pleocytosis, elevated protein and low glucose) suggest tuberculosis. However, the patient appears clinically too healthy to have Tb meningitis. Moreover the diffuse lymphadenopathy, hepatic and splenic involvement makes entities such as lymphoma or sarcoidosis real considerations.
Both can present as suprasellar masses with meningeal involvement. The normal ACE level does not rule out Sarcoid.  The low TSH and LH demonstrate the effect of the mass on pituitary function.

The next step is to make a tissue diagnosis. I would contact both Pulmonary and IR to determine the best location to biopsy. I would avoid a brain biopsy if possible.

Image: Doctors, accompanied by nurses, on rounds at Bellevue Hospital, 1891.  Courtesy Ehrman NYU Medical Library Archives