Patient Care Neurology & Psychiatry - November 2007 - (Page 27)

Case Comment Medical mysteries to sharpen your diagnostic skills & Eosinophilia and persistent myalgias I Case A 57-year-old white woman presents to the family medicine clinic for a routine follow-up visit complaining of myalgias of the lower extremities, progressively worsening cognitive changes, headaches, and epigastric discomfort. Persistent and worsening myalgias of the lower extremities are the most troubling of these complaints. Intermittent thigh pain with exercise began several months ago and progressed to the calf, occurring several times a day in the past several weeks. The patient describes the pain as a cramp that occurs both at rest and with exercise, rating it as excruciating (10 out of 10 on the pain scale). The patient has attempted no specific treatments. She is taking carbidopa/levadopa (Sinemet) for restless legs syndrome (RLS), though it no longer controls her symptoms. In addition to the myalgias, she has been experiencing cognitive changes for several months. She describes them as a periodic inability to find words and a transposition of letters while doing crossword puzzles. The headaches also began several months ago, usually temporal or frontotemporal in distribution and alleviated with rest. The epigastric pain is described as aching and usually occurring at night or before meals with some associated nausea but no vomiting. There is no associated diarrhea, shortness of breath, or chest pain. The patient’s complex medical history includes fatigue, generalized anxiety disorder with panic attacks, moderate sleep apnea, RLS, microcytic anemia, obesity, hypertension, hyperlipidemia, and eczema. Her brother died at age 48 from a massive MI, and her sister, aged 55, has a history of 2 MIs. Her daughter suffers from Sjögren’s syndrome. The patient reports having a sulfa allergy. On examination, the patient is in mild distress because of the pain in her left lower extremity. All vital signs are stable. The cardiac exam is unremarkable, and there are no signs of peripheral vascular disease. There are noticeable asymmetric deviations in the distal phalanges of both hands. Her ankle-brachial index is normal (1.05), and the ECG reveals no abnormalities. The rest of the physical examination, including a thorough neurologic exam, is unremarkable. A preliminary CBC showed an RBC count of 5.16 106 cells/ L, an elevated eosinophil count of 1270 cells/ L (14.6%), and a basophil count of 774 cells/ L (8.9 %). Ferritin, vitamin B12, and folate levels are normal. Adjunct studies, including a comprehensive metabolic panel, ESR, antinuclear antibodies, aldolase, rheumatoid factor, stool ova and parasites, and a creatine kinase isoenzyme panel, are all normal. C-reactive protein is mildly elevated. A cardiac stress test shows poor tolerance at 2.2 minutes of exercise with borderline ischemia; for this problem, she is being appropriately managed by a cardiologist. An upper endoscopic examination reveals a peptic ulcer requiring treatment for Helicobacter pylori infection. On a subsequent visit, the patient reports some relief from her headaches and epigastric pain but no improvement of her myalgias of the lower extremities, which are worsening and occurring more frequently at rest. • What is the diagnosis? • What would be appropriate treatment? I Comment Based on her past history, laboratory results, diagnostics, and progression of symptoms, eosinophilic myalgia syndrome (EMS) was diagnosed, and the patient was placed on a tapering dosage of prednisone. EMS, originally described in the late 1980s in connection with ingestion of L-tryptophan-containing dietary supplements, arose as a public health concern when the investigation focused on postulated product impurities and manufacturing practices. With more than 20,000 consumers affected and more than 200 documented deaths, EMS is probably the most serious outbreak reported in a suspected NOVEMBER 2007 PATIENT CARE NEUROLOGY & PSYCHIATRY 27

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Patient Care Neurology & Psychiatry - November 2007 Contents Research Digest Medicine in the News The 15-Minute Visit Dementia workup and treatment: Do the drugs really work? Help for Your Patients Who Suffer from Specific Phobias Clinical Clips Case & Comment The Science of Healing Classified Advertising

Patient Care Neurology & Psychiatry - November 2007

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