Friday, June 03, 2005

Follow up to: "Subacute dyspnea in a previously healthy 41 year old

Was that patient reading our blog right about neuromuscular disease after all?

Follow up:
Echo: Atypical septal motion, (subtle) inferior wall hypokinesis. Left ventricular function preserved at 52-55%. Mild prominent right sided chambers. PERICARDIUM: Small pericardial effusion.
COMMENTS: Consistent with mild pulmonary hypertension.

Cardiology eval did not add much. They felt the pulmonary hypertension was due to her "lung disease" even though I'm not sure she has much lung disease---

F/U PFT's (1 month after the the first set of full PFT's):
FEV1 87% predicted
FVC 80% predicted
TLC: 84% predicted
RV: 94% predicted
DLCO: 97% predicted

These are all improved significantly, and her flows are now better than her inital post-bronchodilator values. Now, there is no response to bronchodilator challenge.

Interestingly, her MIPS and MEPS are profoundly decreased (MEP of 28 (138 +/- 39 is normal, and MIP of -37 (-91 +/- 25 is normal)

Finally, her CPET is confusing! Her lactate increased to 5.8, but no clear AT was identified. Her HRR and O2 pulse were normal. But, sheh did have a mechanical ventilatory limitation, with elevated ventilatory equivalents and a decreased ventilatory reserve. Finally, her Vd/Vt increased with exercise.

Also, there were mild inferior ST segment changes (consistent with her echo).

I'm not good with CPETs, but FJM said that "Study could support a cardiac limitation plus pulmonary mechanical limitation. A neuromuscular limitation could account for the latter."

So--any more thoughts? Looks like I've treated her airways obstruction. I'll see her next week and see if she's feeling better. I'm thinking that w/u for neuromuscular disease may actually be in order.

2 comments - CLICK HERE to read & add your own!:

Anonymous said...

Two suggestions:

1. place the above link to the original post in html. Like so:

Follow-up to subacute dyspnoea case, which may actually have been correctly diagnosed as a neuromuscular disease by a patient reading our blog!

I can't show you how to do this here because the comment boxes automatically convert examples to links, but there is an easy way to do it in the Blogger posting box. The other guys who added the links on this blog's roll can show you.

2. Add follow-ups in the actual post itself. Just click on edit post, and write FOLLOW UP or UPDATE or something at the bottom, and add your follow up there. Don't add it in the comment boxes, later readers may miss it. If you want first time readers to that post not to see the follow up first, then add the new info in a new post like this one and link both posts.

Just sayin.

Jennings said...

Interesting. My original suggestion that toluene lead to RADS still holds up. According to emedicine (and I didn't look up the refs to this), "Toluene affects skeletal muscle; rhabdomyolysis, myoglobinemia, and a severe muscle weakness similar to Guillain-Barré have been reported."

SO exposure to the toluene-containing paint thinner may explain the whole constellation of symtpoms...