Internal Medicine
Board Review

Educational Objective:

Diagnose endometrial carcinoma.

Key Point:

Any woman older than 35 years old with anovulatory bleeding is at risk for endometrial carcinoma. Obese patients with prolonged anovulation are at increased risk regardless of age.

Explanation:

An obese patient with persistent abnormal bleeding unresponsive to medical therapy requires endometrial biopsy to evaluate for endometrial cancer. Obesity is associated with conversion of androgens to estrogens and chronic anovulation, and therefore obese patients with prolonged anovulation may be at increased risk of developing endometrial hyperplasia and carcinoma regardless of age. Based on age alone, endometrial assessment to exclude cancer is indicated in any woman older than 35 who is suspected of having anovulatory bleeding (risk of endometrial cancer age 35-39 was 6.1/100,000 in 1995). Cyclic treatment with oral progesterone, a Mirena intrauterine device, or injectable progesterone may all be appropriate treatments for this patient following endometrial sampling.

References:

Management of Anovulatory Bleeding. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Compendium of Selected Publications 2008; 1049-1056.

Collings JL, Borm NA. Dysfunctional Uterine Bleeding. Emergency Medicine. 2013; 124: 1069-1068

Educational Objective:

Select the most important initial tests to perform for suspected cases of syncope.

Key Point:

ECG is the most important initial test after an episode of syncope.

Explanation:

This patient’s diagnostic evaluation should begin with a history, physical examination, and ECG. ECG is important to evaluate for abnormal heart rhythm, conduction abnormalities, and ischemia.

CT of the head is unlikely to have much yield in a patient with syncope and normal findings on a neurologic examination. Laboratory tests, such as CBC, should be guided by the patient's history and physical examination findings, and, in the absence of suggestive findings on those, is unlikely to yield a diagnosis. Carotid duplex scanning is not likely to be diagnostic, because transient ischemic attack caused by an embolus from carotids would not be likely to lead to loss of consciousness, which would involve both cerebral hemispheres.

References:

Freeman R. Syncope. In Kasper D, et al, eds. Harrison’s Principles of Internal Medicine. 19th ed., 2015.

Gauer R. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

Quinn J. Syncope in emergencies. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 8th ed., 2016:360-365.

Educational Objective:

Review the latest FIGO cervical cancer stages

Key Point:

 FIGO staging of cervical cancer is based on a combination of clinical, imaging, and/or pathological findings.

Explanation:

The FIGO Gynecologic Oncology Committee and related societies and organizations revised the staging for cervical cancer in 2018, allowing for the incorporation of imaging and/or pathological findings and clinical assessment of tumor size and disease extent.

Stage I cervical cancers- defined as diagnosed only by microscopy with maximum depth of invasion < 3mm (IAI) or < 5mm (!A2)

Stage IIA cervical cancer- defined as involvement limited to the upper 2/3rds of the vagina without parametrial involvement. IIAI are lesions < 4cm. IIA2 are >4cm. IIB lesions are those that involve the parametrium. 

References:

Bhatla N, Berek ST, Fredes MC, et al. Revised FIGO Staging for Carcinoma of the Cervix Uteri, Int J Gynaecol Obstet, 2019; 145: 129-135

Educational Objective:

Evaluate a case of suspected obscure gastrointestinal bleeding.

Key Point:

CT enterography is the most appropriate test to evaluate for malignancy and a source of bleeding in a patient with a history of bowel obstruction and abdominal malignancy.

Explanation:

In the evaluation of iron deficiency and suspected obscure gastrointestinal bleeding (OGIB), various modalities can be utilized after EGD and colonoscopy fail to provide a diagnosis. These options include video-capsule endoscopy, push enteroscopy, spiral or balloon-assisted endoscopy, technetium 99m-labeled red blood cell nuclear scan, angiography, and small bowel follow through, among others.

Video-capsule endoscopy, where available, is often recommended as the recommended next evaluation after EGD/colonoscopy for OGIB. The diagnostic yield for capsule endoscopy can range from 38% to 83% in OGIB. Contraindications to capsule include a history of bowel obstruction due to the potential for capsule retention and risk of perforation. In a patient with a history of bowel obstruction and a history of abdominal malignancy, CT enterography would be the test of choice to evaluate both for a source of bleeding and for the presence of malignancy.

PET may be helpful in identifying a hypermetabolic lesion, but it would not identify benign causes of OGIB. Diagnostic laparoscopy is not indicated for the evaluation of OGIB. Estrogen/progesterone therapy has been used to treat OGIB (likely with an effect on angiodysplastic lesions), but these results are variable and would not be advised until a thorough workup has been performed.

References

Agrawal JR, Travis AC, Mortele KJ, et al. Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy. J Gastroenterol Hepatol. 2012;27:751-759.

Pasha SF, Hara AK, Leighton JA. Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm. Gastroenterol Hepatol (NY). 2009;5:839-850.

Teshima C. Obscure gastrointestinal bleeding. In: Kozarek R. Endoscopy in Small Bowel Disorders. 2015:127-139.

Wang Z, Chen JQ, Liu JL, Qin XG, Huang Y. CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Radiat Oncol. 2013;57:263-273.

Educational Objective:

Diagnose West Nile virus infection.

Key Point:

Immunocompromised patients and elderly are at risk for West Nile neuroinvasive disease. Confirm diagnosis by detecting West Nile antibodies.

Explanation:

The patient has acquired West Nile virus infection, a mosquito-borne disease that has become endemic in the United States. Different regions have been affected more prominently over the years, with Dallas being hit during the late spring of 2012. The disease may cause undifferentiated fever, myalgias, malaise, headache, macular or maculopapular rash, or neuroinvasive disease. Immunosuppressed patients and the elderly are at higher risk of developing neuroinvasive disease. Most commonly, a picture of encephalitis ensues and, less frequently, aseptic meningitis. Characteristically, West Nile virus can cause manifestations resembling Parkinson disease, including coarse tremor, rigidity, and bradykinesia. Results on computed tomography of the brain are usually normal, but MRI findings may show hyperintensity in the basal ganglia, thalamus, caudate nucleus, brainstem, and the spinal cord in T2-weighted images. The disease is confirmed by the finding of antibodies in the serum or in the cerebrospinal fluid.

Chikungunya is a disease that caused a dramatic outbreak in Reunion Island and has now become a pandemic. Autochthonous cases have been reported in the Americas, including the United States. The disease can cause fever and rash, but the predominant manifestation is polyarthritis (the name means "the disease that bends" in a local African language) and neuroinvasion is quite rare. In addition, the incubation period is much shorter than 2 months.

Syphilis can cause meningitis, meningovascular disease, and general paresis. Herpes simplex virus type 1 infection can cause encephalitis. Neither of them causes parkinsonian symptoms.

A striatal dopamine transporter imaging is a sophisticated positron emission tomography scan that can identify parkinsonian syndromes, but it will not be able to determine West Nile virus as the cause.

References:

Carson PJ, Borchardt SM, et al. Neuroinvasive disease and West Nile virus infection, North Dakota, USA, 1999-2008. Emerg Infect Dis. 2012;18(4):684-686.  

Robinson RL, Shahida S, Madan N, Rao S, Khardori N. Transient parkinsonism in West Nile virus encephalitis. Am J Med. 2003;115(3):252-253.