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Episodes of uneasiness, sinking and suffocation - need a diagnosis (17 Nov 2008)



Case Submitted By - DR SUNIL M JAIN, DM [Endocrinology], Indore, India

You are most welcome to submit your opinion and solve the puzzle.


Age 44 yrs. Male, non-smoker, non–alcoholic and vegetarian, is a known case of T2 Diabetes.

Family History:  Father — Hypertension, CAD, Cerebral haematoma, 
                         Mother —Type 2 Diabetes with Hypothyroidism and Bronchial Asthma,

History: Diagnosed as T2 DM 5 years ago. He was on Metformin 500 mg twice a day initially and then 1 gm. SR 2 times of a day with fairly good control of DM.

He had a severe road traffic accident in April 2005 with intertrochanteric fracture of left femur and four part fracture dislocation (posterior) of left shoulder and lacerated wound over scalp which recovered fully without any complication.

Meanwhile on 25.07.08, he had severe uneasiness, suffocation and sinking feeling at home having consumed 50 – 100 gm of sugar & was shifted to hospital. ECG, Chest X-ray PA view, 2D echo, Trop + were done which were all normal. RBS was 140 mg% by glucosemeter and was sent back home.

Next day morning he was fine and went for a routine ECG checkup for minimal chest discomfort which showed mild ST elevation in lead III ( already had Mild ST Elevation lead III for years without any symptoms). He had severe uneasiness, sinking feeling, suffocation and breathlessness after ECG was being taken and rushed to hospital where CAG was done on same day that is 26th July 08, which showed almost normal coronaries but with sluggish flow in all vessels. He was immediately given Intracoronary RheoPro.

At time of discharge, He was put on Diltiazem 180 mg, Nicorandil 10 mg, Ramipril 2.5 mg. and Plavix 75, Aspirin 150 mg & Metformin 1 Gm BD.

He did well for next 5 days and was discharged from hospital on 30.07.08 morning.

Again on the same evening, i.e. 30.07.08, he had severe drenching perspiration, Ghabrahat and shortness of breath. He took around 50 – 100 gm sugar (after checking RBS which was 70 mg%. Again ECG was taken in the hospital which was normal. He became alright in 30 minutes without any medication.

A detailed evaluation was planned.

Experts involved- Endocrinologist- His Endocrinologist suggested him to undergo extended OGTT. Next day on 04.08.08 a 5 hrs extended GTT was done.

Glucose Tolerance Test : 

Time

Laboratory

10.00 am

106

11.05 am

215

12.05 pm

302

1.05 pm

123

2.05 pm

105

3.05 pm

110

 



 

 

Next day, Metformin was kept omitted and a continuous Glucose monitoring using Guardian RT was performed. (Please view attachment for the Guardian RT Data)

Gastroenterologist :
Suspected Carcinoid syndrome and asked for investigations.


Neurologist :
Considered a non neurological cause.


Cardiologist  : 
Did a reevaluation of cardiac status. ECG was taken on 06.08.08 at rest & after 25 minutes walk, both normal.


TMT (Stress Test) 14.08.08


1. Test is negative for Ischaemia.
2. Good effort tolerance
3. No significant ST – T changes during exercise and recovery


Biochemistry revealed following abnormalities on 04.Aug.08:
 
 

Examination of Blood

Result

Unit

Reference Range

Apolipoprotein A1

0.67

 

0.89 - 1.86

Triglycerides

231

mg%

40 - 100

S.G. O.T.

60

U/L

Blood 10 - 40

S. G. P. T.

163

U/L

Blood 10 - 40

Gamma GT - GGT

87

U/L

Blood 10 - 50

Glucose F (Enzymatic)

179

mg%

Blood 70 - 110

Glucose F ( Enzymatic )

143

mg%

Blood 70 - 110

 

 

 

 

 

Test Reports Done on 11.Aug.08

Examination of Blood

Result

Unit

Reference Range

L.D.L. Cholesterol

157

mg%

80 - 130

S.G.O.T.

35

U/L

10 - 40

S.G.P.T.

77

U/L

10 - 40

Gamma G. T.

74

U/L

10 - 50

Glycosylated Haemoglobin

6.6

% of total HB

4.8 - 5.9

5 - HIAA

8.5

mg / 24 hrs.

2 - 6



 

 

 

 

(Please view attachment for the detailed reports)

Whole body CT Scan
was performed on 13-Aug-2008 and the outcome was reported as:

1 Liver: Patchy irregular enhancement seen along segment 7 of the liver in late arterial phase with contrast was out in venous and parenchymal phase is s/o (THAD) transient hepatic attenuation difference (THAD).

2 Nasopharynx: Midline hypo dense rather separated minimally peripherally enhancing nasopharyngeal lesion is of undermined etiology
.

Possibilities:

A Tornwaldts Cyst
B Less likely nasopharyngeal carcinoid


Nasal Endoscopy
was performed on 14.08.08 in which Benign Cystic swelling was seen in nasopharynx

This patient was given a simple treatment and problem was solved.

 

Thus, this type 2 Diabetic patient had episodes of uneasiness and sinking, initially treated as Coronary problem and received Rheopro, also given 80 mg Atorvastatin and other drugs for CAD, but problem recurred so detailed evaluation done and biochemical abnormalities like deranged liver function tests were considered to be iatrogenic but also had elevated 5 HIAA  SO Carcinoid syndrome was also kept as differential diagnosis.His extended GTT and Guardian RT data are also interesting.

 

This patient was given a simple treatment and problem was solved. 

 

This Puzzle is open for discuss and you are most welcome give your opinion.

 

Please Click blow mentioned link " View Attachment " to view other detail of  the case including  biochemistry, CT images, Angiography image, Guardian RT data.

 


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