Pleural effusion+ RHF ?ank spond ?fluorosis
60 yr old male pt agricultural laborer residing at Nalgonda District presented to the OPD saying "I was completely normal 2 and half years back then one day I had electric shock like sensation in my lower back and burning sensation in both my legs occasionally.. I was alright for about 6 months and suddenly I felt burning sensation in both my feet a/w tingling and pins and needles sensation so much that I couldn't even get up from my bed.Later I had difficulty in walking and I felt like I was walking over the rope while walking. My footwear did not slip away. Yes.. I felt the sensation of clothing on me.. I was able to differentiate between hot and cold water while bathing. But I felt the same burning sensation in my hands up to wrists but I had no difficulty in mixing food and combing my hair.But my neck is so stiff that when I lie down its difficult for me to sleep without pillow because i cannot touch the bed with back of my head and without pillow my head stays in air(since 2yrs). I had no bowel or bladder incontinence.. with all these complaints I went to hospital and the doctor advised MRI spine.Based on the findings they said I have to undergo surgery but they said they can't guarantee the results of surgery. So I got frightened and I refused surgery and since then I was using this (He pointed towards his walker). So I started taking painkillers to relieve my backache and leg pains.
Since 15days "I am passing less urine after which my legs are swollen and are appearing shiny, my abdomen appears to be distended, I also have cough with sputum, and shortness of breath which aggravates on exertion and relives only when I take rest.On enquiry.. there's no h/o orthopnea and PND. I don't know why but I am having more sputum in sitting position and less while I am laying down, which is white in colour, moderate in amount, not blood tinged and non foul smelling, I neither had fever nor lost my weight. I never had any syncopial attacks. I don't have diabetes, hypertension, asthma, TB. I smoke 20 cigars per day since 35 years. I used to take alcohol (since 30 yrs) but i gave up 2yrs ago..only my urine output is decreased and I am passing stools normally with no difficulty. I take mixed diet but my appetite got decreased since few days.. and I am sleeping well. yes.. we used to take fluoride water previously but now we shifted to other water source and this doesn't contain any fluoride.
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| STIFF NECK |
Pt is conscious, cooperative and well oriented to time, place and person.
Thin built, ill nourished
Vitals:
Temp- 98.4°F
Resp- 37cpm
BP- 100/70mmHg
Pulse- 106bpm
JVP is raised
pitting edema, grade II, slow filling.
SYSTEMIC EXAMINATION:
Examination of Respiratory system:
On Inspection, pt is breathing with mouth, supraclavicular hallowing more on rt side.
chest wall movements are almost nill on both sides.
On measuring, Chest expansion is zero
On percussion, dull note is heard over left inframammary, infraaxillary and infrascapular areas
On auscultation there is decreased air entry in both sides,
Crepitations are heard in left inframammary and infraaxillary areas.
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| SHINY LEGS WITH PEDAL EDEMA |
Examination of Cardiovascular system:
rise in JVP is seen.
no visible pulsations,
Apex beat is shifted downward and outward
Skeletal system examination:
Axial skeleton:
cervical spine: Gross restriction of movements
dorsal spine: no chest expansion
Kyphosis
diaphragmatic movements +
lumbar spine: Gross restriction of movements
sacral spine:Gross restriction of movements
peripheral skeleton:
shoulders: }
ankle: } limitation of movements
feet: }
elbows }
wrists } fair
hands }
knee }
Teeth:
discolored, mottled, pitting and serrated teeth are seen
ivory teeth appearance in lower teeth
Unable to touch the wall with back of head while standing against the wall.
Schobers test was negative (16cm)
examination of central nervous system:
pt is conscious, co-operative and well oriented to time, place and person
Higher mental functions: normal
cranial nerve examination is normal
motor system examination:
bulk: equal on both sides
tone: stiffness is increased in all four limbs
power: normal
reflexes:
Biceps Triceps Supinator Knee Ankle Plantar
Rt N N N decreased decreased extensor (exaggerated)
Left N N N decreased decreased extensor (exaggerated)
knee reflex showed previously hyperreflexia according to the pt. he said his leg used to raise up forcibly when some does the same (checking knee reflex in supine position) not a leading question either.
All components of Babinski are seen except dorsiflextion of great toe (may be due to stiffness)
sensory system examination: sensations are impaired below L1
no cerebellar signs, no signs of meningeal irritation.
Abdominal examination:
per abdomen is soft, non tender, no organomegaly
INVESTIGATIONS:
Anti HCV antibodies }
HBsAg } negative
HiV }
U/S chest
Free fluid noted in bilateral pleural spaces
Air sonograms noted in left lung
Impression
Moderate left pleural effusion with left lung consolidation
Minimal right pleural effusion
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scapular border is abnormal. calcification is seen along the insertions of muscles.
increased bone density.
Pleural fluid protein / Serum protein >0.5.
Pleural fluid LDH / Serum LDH >0.6.
Pleural fluid LDH > 2/3×Serum LDH Upper Limit of Normal.
2.3÷6.8= 0.3 (<0.5)
42÷174=0.24 (<0.6)
So it's transudate
pleural fluid ADA<9 mg/dl
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| ABG ANALYSIS: PCO2 DECREASED, PO2 DECREASED |
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| RENAL FUNCTION TESTS- UREA IS SLIGHTLY INCREASED |
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| LIVER FUNCTION TESTS: ALP INCREASED |
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| ECG |
2D echo
Grossly Dialted right atrium and right ventricle
D shaped left ventricle
No obvious left ventricular regional wall motion abnormalities
Severe pulmonary arterial hypertension
Right ventricular systolic pressure 110mmHg
Severe Tricuspid regurgitation (TS)
Severe pulmonary arterial hypertension (PAH)
Good LV systolic function
LA 2.7cm
LV ejection fraction 65%
IVC Dialted and not collapsing
No MR/AR
No PE
Here u can see contiguous
ossification of
posterior longitudinal ligaments from C4 to C6 which is causing cord
compression with cord thinning and cord myelomalacia. Uncovertebral and facet joint osteoarthritic
changes causing B/L neural foraminal narrowing from C3 to C4.
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| MRI DORSO-LUMBAR SPINE AP VIEW
osteophytes are seen
linear central line indicates calcification of supraspinous ligament
sacroiliac joints are obliterated
calcification of sacrospinous ligaments on both sides
calcification of acetabular labrum on both sides.
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| MRI DORSO-LUMBAR SPINE LATERAL VIEW |
posterior facet joints are all calcified
calcification of anterior longitudinal ligaments
calcification of posterior longitudinal ligaments
causing cord compression and cord thinning with myelomalacia
anteroposterior distance is decreased
HRCT images of thorax in axial plane:
HRCT images of thorax in axial plane showing
consolidation in the basal segments of lower lobe, mild pleural effusion
dilated
right atrium and rt ventricle. Mild pericardiac effusion
Skeletal
f/o diffuse
idiopathic skeletal hyperostosis
{DISH}.
HRCT thorax axial plane showing dilated pulmonary artery
HRCT Thorax coronal plane showing left pleural effusion.
FINAL DIAGNOSIS:
Left sided pleural effusion with consolidation, with secondary heart failure
with ankylosing spondyloarthropathy ?flourosis induced
TO BE DISCUSSED...
why previously there was hyperreflexia and now the reflexes are decreased?
so what is the reason for his pleural effusion? what is the reason for his consolidation? Did pleural effusion led to consolidation or consolidation led to pleural effusion?
what is the cause of this transudative effusion?
why did he develop right heart failure?
is that due to pulmonary arterial hypertension?? what is the reason for developing PAH? just his ankylosing spondylitis causing restrictive lung disease?
is ankylosing spondyloarthropathy because of fluorosis? if so, whats the diagnostic criteria to confirm its because of fluorosis?
just epidemology?
just old age?
just bony changes? Are there any differentiating features in the skeletal changes of ankylosing spondylosis and that of fluorosis? if so, what are they?
what more can be added to diagnostic criteria?
How to manage this patient??
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