Causes of Encephalopathy - Differential Diagnosis Algorithm
Hyperacute:
- Primary Neurologic: Vascular (IS, ICH), Seizure, Migraine, Trauma
- Systemic: Hypertensive encephalopathy
Acute:
- Primary Neurologic: Vascular (SDH), Inflammatory (Acute demyelination), Infectious (bacterial/viral meningitis encephalitis)
- Systemic: Systemic infection
Subacute:
- Primary Neurologic: Vascular (SDH), Neoplasm-related (brain tumors, paraneoplastic syndromes), Inflammatory, Infectious (fungal, TB, parasitic, complications of HIV)
- Systemic: Chronic systemic conditions: Heart failure, Endocrinopathy, Malignancy, Autoimmune, OSA
Chronic:
- Primary Neurologic: Vascular (SDH), Degenerative, NPH, Infectious (syphilis, HIV-associated neurocognitive disease)
#Encephalopathy #Differential #Diagnosis #Algorithm #Causes
Causes of Painful Ophthalmoplegia - Differential Diagnosis
• Trauma
• Autoimmune:
1. Sarcoidosis
2. GPA
3. Eosinophilic granuloma
4. Tolosa-Hunt syndrome
5. Giant cell arteritis
• Infectious:
1. Bacterial: Treponema pallidum, contiguous sinusitis, mucocele, periostitis, abscess
2. Viral: Herpes zoster
3. Fungal: Mucormycosis, actinomycosis
4. Mycobacteria
• Vascular:
1. Carotid-cavernous fistula
2. Carotid-cavernous thrombosis
3. Aneurysms of the intracavernous carotid artery, posterior cerebral artery, or posterior communicating artery
4. Internal carotid artery dissection
• Neoplastic:
1. Intracranial tumors: pituitary adenoma, meningioma, and craniopharyngioma
2. Local metastases: nasopharyngeal tumor, squamous cell carcinoma
3. Other distant tumors: Lymphoma, Multiple myeloma, carcinomatous metastases
• Others: ophthalmoplegic migraine
• Image-negative:
1. Ocular diabetic neuropathy
2. Ophthalmoplegic migraine
3. "Benign" Tolosa-Hunt syndrome
#Painful #Ophthalmoplegia #Causes #Differential Diagnosis #ophthalmology
Causes of Secondary Hypertension - Workup and Differential Diagnosis
Approach (when evaluation should be done):
1. Severe or resistant hypertension: Resistant hypertension is defined as the persistence of hypertension despite concurrent use of adequate doses of three antihypertensive agents from different classes, including a diuretic.
2. An acute rise or increased lability in blood pressure developing in a patient with previously stable values.
3. Age less than 30-40 years in non-obese, non-black patients with a negative family history of hypertension and no other risk factors (eg, obesity) for hypertension.
4. Onset of diastolic hypertension at an older age (> 55 years)
5. Malignant or accelerated hypertension (eg, patientswith severe hypertension and signs of end-organ damage such as retinal hemorrhages or papilledema, heart failure, neurologic disturbance, or acute kidney injury).
6. Hypertension associated with electrolyte disorders including hypokalemia and metabolic alkalosis.
7. Proven age of onset before puberty.
8. Stage 2 hypertension (blood pressure >160-179/100-109 mm Hg) with clinical suspicion of either renovascular or endocrine causes of hypertension (eg, presence of renal bruit or signs of hormonal excess or hypokalaemia).
9. Stage 3 hypertension (blood pressure >180/110 mm Hg).
Causes:
• Vascular: Renal artery stenosis, Coarctation of aorta, Vasculitis
• Endocrinologic: Hypothyroidism, Primary Hyperaldosteronism, Hyperthyroidism, Hypercalcemia, Cushing's syndrome, Acromegaly, Pheochromocytoma
• Toxic: NSAlDs, Glucocorticoid, Estrogens, Sympathomimetic, Alcohol, Cocaine, Amphetamines
• Other:
1. Renal parenchymal disease: CKD, acute glomerulonephritis, andscleroderma renalcrisis
2. Obstructive sleep apnea: CPAP, most pts have HTN
3. White-coat syndrome: 24-hour ABPM
4. Pregnancy-associated
5. Neurologic disorders: Increased intracranial pressure (Cushing'sresponse), quadriplegia, dysautonomia, and Guillain-Barre Syndrome
- Dr. Jorge Cortés @Jcortesizaguirr
#Secondary #Hypertension #Workup #causes #Differential #Diagnosis #indications
Ascites - Diagnostic Approach and Differential Diagnosis
The most common causes: cirrhosis, malignancy and heart failure. Approx 5% of patients w/ ascites have more than one cause (e.g. cirrhosis + TB, peritonitis, peritoneal carcinomatosis, HF, etc.).
Physical Exam:
1) Most relevant findings: Fluid wave (LR 5.3), peripheral edema (LR 3.8) / absence of edema (LR 0.17), shifting dullness (LR 2.1) - fluid wave/shifting dullness detect > 1 litre of ascites.
2) Other findings: bulging flanks, flank dullness, puddle sign, auscultatory percussion, abdominal wall hernias (umbilical, inguinal, incisional).
3) Signs of underlying disease: Cirrhosis, Malignancy, Heart Failure
Labs + Ascitic Fluid Analysis:
1) General appearance: Uncomplicated ascites: clear, pale straw-colored yellow, infection: hazy, cloudy or bloody fluid; hemorrhagic: frank blood; chylous: milky fluid; brown: elevated bilirubin
2) Routine tests: Cell count and differential, albumin and total protein concentration
3) Optional tests: Culture in blood culture bottles (infection, bowel perforation), glucose concentration (malignancy, infection, bowel perforation), LDH (malignancy, infection, bowel perforation), gram stain (suspected bowel perforation), amylase concentration (pancreatic ascites or bowel perforation), TB smear/culture/ADA (TB peritonitis), cytology/CEA antigen (malignancy), triglyceride (chylous ascites), bilirubin
concentration (bowel or biliary perforation), Serum pro-brain natriuretic peptide (heart failure)
Dr. Jorge Cortés @Jcortesizaguirr
#Ascites #workup #Differential #Diagnosis #hepatology
Cushing's Syndrome - Hypercortisolism - Diagnosis and Clinical Features
1) Skin
• Thin, easily bruisable skin with stretch marks (classically purple abdominal striae) and/or ecchymoses
• Delayed wound healing
• Flushing of the face
• Hirsutism
• Acne
• If secondary hypercortisolism: often hyperpigmentation (darkening of the skin due to an overproduction of melanin), especially in areas that are not normally exposed tothe sun (e.g., palm creases, oral cavity) Caused by excessive ACTH production because melanocyte stimulating hormone is cleaved from the same precursor as ACTH. Hyperpigmentation is not a feature of primary hypercortisolism.
2) Neuropsychological: lethargy, depression, sleep disturbance, psychosis
3) Musculoskeletal
• Osteopenia, osteoporosis, pathological fractures, avascular necrosis of the femoral head
• Muscle atrophy/weakness
4) Endocrine and metabolic
• Insulin resistance —+ hyperglycemia —+ mild polyuria in the case of severe hyperglycemia
• Dyslipidemia
• Weight gain characterized by central obesity, moon facies, and a buffalo hump
• Male: decreased libido
• Female: decreased libido, virilization, and/or irregular menstrual cycles
5) Secondary hypertension (90% of cases)
6) Increased susceptibility to infections
7) Peptic Ulcer disease
8) Cataracts
Labs:
Hypokalemia (rarely in Cushing's disease; ectopic ACTH production: 1. higher circulating cortisol 2. activity of 11ß-hydroxysteroid dehydrogenase type 2 (prevents mineralocorticoid activity of cortisol) is decreased), hypernatremia, metabolic alkalosis (Due to the mineralocorticoid effect Of cortisol), Hyperglycemia: due to stimulation of gluconeogenesis enzymes (e.g., glucose-6-phosphatase) and inhibition of glucose uptake in peripheral tissue, Hyperlipidemia (hypercholesterolemia and hypertriglyceridemia) and Leukocytosis (predominantly neutrophilic) → demargination of neutrophils from the endothelial lining of vessels, eosinopenia, thrombocytosis.
Screening:
↑ 24-hour urine cortisol
↑ early morning serum cortisol levels following a low-dose dexamethasone suppression test
↑ midnight salivary cortisol
↑ midnight serum cortisol
Imaging:
1) Primary hypercortisolism—+ CT and/or M RI of the abdomen for adrenal tumors
• The adrenal cortex contralateral to the tumor shows atrophy due to reduced ACTH stimulation
2) Cushing's disease —+ CT and/or MRI of the skull
• In Cushing's disease, CT and/or MRI of the abdomen shows bilateral hyperplasia of both the zona fasciculata and zona reticularis
• If no findings are present on neuroimaging, perform bilateral sampling of the inferior petrosal sinus in order to measure ACTH levels
3) Ectopic ACTH production is suspected: chest x-ray and/or CT, abdominal CT, pelvis CT
- Dr. Jorge Cortés @Jcortesizaguirr
#Cushings #Syndrome #Hypercortisolism #Diagnosis #signs #symptoms #endocrinology
