Transcript Journal Club

Clinical Vignette: Medical Grand
Rounds
Joshua L. Denson MD
Internal Medicine PGY2
January 7, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•The patient is a 36 year-old man who
presented with bloody diarrhea and
abdominal pain for 10 days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•3 weeks prior to presentation, the patient
complained of daily small volume, loose,
bloody bowel movements.
•He had urgency to move his bowels and
crampy left sided abdominal pain.
•No recent antibiotic use or hospitalizations
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History: Hyperlipidemia
•Past Surgical History: None
•Social History: Denies tobacco, alcohol,
and drug use. No recent travel. Lives with
his wife, monogamous. No children. No
pets. Works as an accountant.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Family History: Denies family history of
colon cancer or inflammatory bowel
disease.
• Allergies: No Known Drug Allergies
• Medications: None
Physical Examination
•General: well developed man in mild
distress, appears uncomfortable
•Vital Signs: list T: 100.2 BP: 125/70 HR: 99
RR:18 and O2 sat: 100% on ambient air
•Abdomen: tender to palpation left lower
quadrant, some voluntary guarding
•Remainder of Physical Exam normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: hemoglobin level was 10.6 g/dl.
Remainder of CBC was within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
•Stool culture, ova, and parasites within normal
limits
•Fecal Leukocytes were positive
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•CT Abdomen and Pelvis revealed
proctosigmoiditis and left sided colitis
consistent with inflammatory bowel disease
•Colonoscopy revealed friable granular
tissue involving the rectum and sigmoid
colon confirming ulcerative colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Ulcerative Colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Patient was begun on po and rectal 5aminosalicylate acid (5-ASA) as well as po
steroids
• Hospital Day 2-3:
– The patients’ symptoms improved and he was
subsequently discharged home.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow Up
• Follow up Clinic Visit at 6 weeks
– The patient was unable to be tapered off
steroids and was begun on azathioprine
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow Up
• Follow up Clinic Visit 10 weeks:
– Repeat CBC revealed severe leukopenia
– Thiopurine methyltransferase (TPMT) enzyme
activity and genotype were sent
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow Up
• Follow up Clinic Visit 12 weeks:
– TPMT enzyme activity returned low
– TPMT genotype was homozygous for mutant
allele
– The patient was switched to infliximab therapy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Ulcerative Colitis with mutation in the
TPMT gene potentiating myelosuppressive
effects of azathioprine
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS