Dysphagia

SPEAKER_01 0:11

Hello and welcome to the Home of Medicine podcast with me, Dr. Amy Bearbridge and me, Dr. Ben Lovell. This is a podcast in association with the Royal College of Physicians, Edinburgh. So a huge thank you to them for supporting us on our podcast journey. Ben, I have a case for you.

SPEAKER_02 0:30

Yes, I thought you might. Go for it.

SPEAKER_01 0:34

I have a 54-year-old woman who was referred by her GP with a nine-month history of difficulty swallowing.

SPEAKER_02 0:46

Oh, that's okay. Sorry, I reacted a bit soon then.

SPEAKER_01 0:50

No, tell me why you're actually at that.

SPEAKER_02 0:53

I'm an acute physician, and nine months is it's not an acute presentation, it's it's something else. But okay, maybe I'm jumping the gun. I'm interested to hear more.

SPEAKER_01 1:02

So was that response due to the fact that you didn't think it was an acute problem?

SPEAKER_02 1:07

Yeah, yeah. Okay. Not pretty much, yeah. If it's been going on for nine months, unless it's a problem that has been getting worse for nine months, has now reached critical point, i.e., she can't swallow anything. And yes, I'd love to see her and admit her and get her treated. But when um if somebody says, please can you see someone who's had an issue that's going on for the best part of a year? I'm not your guy. Um, I I'm an acute physician, uh, not not uh not a say a GP. And I I don't have a clinic where I see people with chronic illnesses and all that sort of thing. But sorry, I'm being I was a bit grumpy of me. Let me keep an open mind and tell me some more.

SPEAKER_01 1:43

No, but it's really interesting to think about why we have that reaction because we do, don't we? Certain um referrals we get, or and we do have a what your reaction then was a visceral reaction, wasn't it? It was very visceral. It was very visceral, and it was like, oh, I think from deep within.

SPEAKER_02 1:59

Yeah. And I think emergency um physicians would have a similar response, you know, when they say nine months. And so where's the accident in the emergency? But um, as I say, maybe something has changed, and we need to see this woman today. So she should never know that reaction. The patient should never know I did that. I'd say it within the the safety and the secrecy of this podcast.

SPEAKER_01 2:18

Yeah, um, so it's a nine-month history um of difficulty swallowing. Um, and the GP mentioned in the referral letter that there was a productive cough, night sweats, weight loss, amenorrhea.

SPEAKER_03 2:38

Okay.

SPEAKER_01 2:40

I'm gonna stop there. Does that change your reaction a little bit now?

SPEAKER_02 2:44

So is it nine months of all of the above?

SPEAKER_01 2:47

No, this is new. So the uh difficulty swallowing was nine months, and the letter didn't say how long these have been happening for.

SPEAKER_02 2:56

All right, so nine months of difficulty swallowing, and then maybe a more acute or a sub-acute presentation of a productive cough, weight loss, night sweats, and amenorrhea. Okay. Um, all right, I'm gonna park the amenorrhea for now because that's the one I'm sort of least familiar with as a concept. But all right, maybe there is some kind of chronic process which has led to chronic dysphagia, but she also happens to have an acute respiratory infection. Um, now weight loss and night sweats. Weight loss and night sweats, that speaks to me of malignancy or indolent diseases such as TB. TB could give you a chronic cough. Um, so we need to know some more information about that, hematological problems. I suppose you could say that a 54-year-old woman who had some night sweats and amenorrhea had these menopausal symptoms, but of course, that should not give you difficulty swallowing productive cough uh or weight loss, I believe. So we'll we'll just put that over here for now. Um, all right, then let's have some more information.

SPEAKER_01 3:57

What else would you like to know?

SPEAKER_02 4:00

Let's do the oh let's do, let's start with the acute problem. So, how long has this cough been going on for, first of all?

SPEAKER_01 4:06

So the cough has been present for two to three weeks. So, on further history taking when I met the patient, it was difficult to pin down the exact length that this had happened for. So, although she said it was two to three weeks, potentially it could have been longer. So it certainly wasn't within the last five days. You know, it was definitely been going for a lot longer than that. So two to three weeks. Um the night sweats again at all two to three weeks.

SPEAKER_02 4:35

And this cough, productive, you say?

SPEAKER_01 4:37

It was productive, yeah, of sputum, green sputum.

SPEAKER_02 4:40

Okay, that sort of feels infectious, doesn't it? Green sputum coming up with the cough. No blood, though, I should hope. No blood. Okie dokie. Alrighty. So uh that's the cough. Um shortness of breath associated with this?

SPEAKER_01 4:54

Not really, no.

SPEAKER_02 4:56

Chest pain?

SPEAKER_01 4:57

No.

SPEAKER_02 4:58

No pleuritic pain, no. Okay. Good stuff. All right then. Now let's go on to the weight loss. Over what time frame?

SPEAKER_01 5:06

So she's lost around three stone. So what would what would that be in kilos?

SPEAKER_02 5:11

Um, okay.

SPEAKER_01 5:13

Around six, about twenty kilos, maybe.

SPEAKER_02 5:17

Um now a pound is like two kilos, or is the other way around?

SPEAKER_01 5:21

No, a kilo is two point two pounds.

SPEAKER_02 5:25

Right. Let's just stop being silly and ask Chat GPT. Um, but okay, she's lost she's lost a lot of weights. Over what time frame?

SPEAKER_01 5:33

Yeah. Um, so she said that she's had a reduced appetite that she remembers around four to five months. Um, so she just hasn't been eating as much. So she thinks it's been around four to five months that the weight loss has been going on.

SPEAKER_02 5:47

Four to five months. Oh yeah, 19.5 kilos.

SPEAKER_01 5:51

Um, that was a good guess from me, wasn't it?

SPEAKER_02 5:54

It was very good. So uh four to five months. Now, and you and she thinks she's losing weight because she's not eating, because she's not hungry.

SPEAKER_01 6:00

Yeah, exactly.

SPEAKER_02 6:01

Right, right, right. So she's not eating lots and lots of still burning off, right? Okay. You wonder if her thyroid's gone a bit wonky. That could be causing some difficulty swallowing, could be causing um yeah. All right. Um, what am I writing down? Four to five months, reduced apetite. What about bowel habit?

SPEAKER_00 6:20

Normal.

SPEAKER_02 6:21

Normal and no bleeding, uh no GI bleeding. No normal bowel habit. Okay. Uh night sweats, how long?

SPEAKER_01 6:30

Again, quite difficult to ping down, but she says she's noticed it for around two to three weeks.

SPEAKER_02 6:37

Oh, okay, so quite a short time frame. Two to three weeks. Um, all right, and when you say night sweats, we're talking drenching sweats, get out of bed and change your pajamas, sort of thing.

SPEAKER_01 6:50

That drenching sweats in the bed at night where you wake up and I get it sometimes, not very often. Um, but normally when you're ill, you've got a cold or something like that, or um a really heavy default, and it's that horrible you wake up in the night and you feel cold because the sweat's almost dried on you. Um and yeah, so that's a drenching sweat where the sweat goes through the pajamas and onto the bed sheets as well, and everything's sort of like ringing wet. So they need to be changed.

SPEAKER_02 7:20

So weight loss and night sweats, just thinking about malignancy B symptoms. A quick check. Any lumps or bumps you've noticed anywhere on your on her body, any uh lymph nodes coming up?

SPEAKER_01 7:31

She commented that her neck felt swollen.

SPEAKER_02 7:35

Oh dear. Itchy?

SPEAKER_00 7:39

No, no itchy.

SPEAKER_02 7:43

Okay, yeah, no itch. All right. Uh energy levels?

SPEAKER_01 7:48

Pretty poor. Um, normally was able to work, worked part-time, um, but you know, was still going to work, but was pretty exhausted by the end of the day.

SPEAKER_02 8:02

All right then. Okay, I've got a sense of that. And then um let's go to the difficulty of swallowing now. So you nine months of this. What do you what's what's meant by difficulty swallowing? Things won't go down, they're getting stuck, they're coming up, they're hurting.

SPEAKER_01 8:17

She feels like things get stuck at the back of the throat, and there's a little bit of pain as well. So there's a little bit of audenophasia. When I asked her to point out, I often find it quite helpful to imagine the the food pipe, the esophagus, say to a patient, um, whereabouts does the food get stuck and they pinpoint it. And hers was really high up, actually. It was sort of at the back of the throat rather than further down in the esophagus.

SPEAKER_02 8:43

Like pharyngeal.

SPEAKER_01 8:44

Almost pharyngeal, yeah. Yeah.

SPEAKER_02 8:46

Had she noticed a swelling at the front of her neck, a big fat thyroid goita?

SPEAKER_01 8:50

No.

SPEAKER_02 8:51

Okay, thank you.

SPEAKER_01 8:52

No, she just felt that, you know, when you feel your lymph nodes in your neck.

SPEAKER_02 8:55

Yeah.

SPEAKER_01 8:55

But that was, and to be fair, I couldn't see a goiter or a pharyngeal pouch or anything like that, so no.

SPEAKER_02 9:01

Um, and uh any vomiting?

SPEAKER_01 9:04

No.

SPEAKER_02 9:05

Or regurgitation?

SPEAKER_01 9:06

Yes. She felt that a feed does regurgitate. So when it does go down, she feels a really nasty taste in her mouth.

SPEAKER_02 9:15

And this lack of appetite and the weight loss, in her mind, is this tied together with the swallowing issue? Yeah. She doesn't want to eat because it's such a distressing thing to do.

SPEAKER_01 9:25

Exactly. And she's put it all in one basket, you know, it all feels like it's the same thing. Absolutely.

SPEAKER_02 9:33

Gotcha. Does food go down the wrong hole? Does she choke, aspirate, splatter, and cough when she swallows?

SPEAKER_01 9:39

I didn't ask that. I'm just going to do that. That would have been a really good question. Yeah, that's a very good question, actually. And I didn't ask that, and I should have done. Um, particularly with poor swallowing, so I didn't ask that. So should have done.

SPEAKER_02 9:54

Right. And now I both both of her touched upon the amenorrhea. So could you just describe that a bit for me?

SPEAKER_01 10:00

Just no periods for three months. That was all she said. She's normally quite regular with her periods. As I say, she's 54. So um she was sort of expecting um the menopause anyway. Um, but prior to that, actually her periods were regular.

SPEAKER_02 10:15

Um okay. She has not yet experienced the menopause as well. Yeah. She's a very good thing. She's a sheet, though. Yeah, officially. Um in which case I have to ask the question: any chance she could be pregnant?

SPEAKER_01 10:27

No. Um, and that's a really good point, isn't it? And we've said this often any woman is pregnant until proven otherwise. And um just because somebody's in their early 50s does not mean they cannot be pregnant. So um, I'll often say, Can we have a pregnancy test? And they'll go, Really? Um I mean, I'm 54 or whatever age it is. Um, so we did a pregnancy test, and the pregnancy test was negative.

SPEAKER_02 10:51

Right. Good. Okay. Um now any past medical history?

SPEAKER_01 10:56

Yes. So she has had dysphagia in the past as well. Um but nothing else of note um apart from this dysphagia, which she had a few years before.

SPEAKER_02 11:12

And what happened then?

SPEAKER_01 11:14

Nothing.

SPEAKER_02 11:15

Never saw a doctor?

SPEAKER_01 11:16

Nope. How long did it last? A few months and then settled and went away.

SPEAKER_02 11:24

Exactly the same as this, or was it?

SPEAKER_01 11:26

She says it was similar, although she can't remember exactly what was going on. It was a couple of years ago. Um, she felt pretty rough, was having difficulty swallowing, um, and then it just seemed to settle down.

SPEAKER_02 11:39

But did she lose the weight and have the night sweats along when she had that? No. Appetite, but oh okay. So this maybe is a similar but worse.

SPEAKER_01 11:49

Potentially, yeah, yeah.

SPEAKER_02 11:51

All right. Any other past medical history?

SPEAKER_01 11:54

No.

SPEAKER_02 11:55

All right, medications?

SPEAKER_01 11:57

She doesn't take any medications at the moment at all.

SPEAKER_02 12:00

And no allergies.

SPEAKER_01 12:01

No.

SPEAKER_02 12:03

And what about social history?

SPEAKER_01 12:06

She smokes five cigarettes a day.

SPEAKER_02 12:08

Mm-hmm.

SPEAKER_01 12:09

But has smoked more than this in the past. But she said around 10 years ago she cut down her smoking, but she was a heavy smoker. And when I asked what do you mean by a heavy smoker? Um, 20 a day, but now she smokes five cigarettes a day. Um, she denied any alcohol intake and said that she's never been a heavy drinker. Um, and as I say, she works part-time.

SPEAKER_02 12:31

Doing what sorts of stuff?

SPEAKER_01 12:33

She works in a bank. Okay.

SPEAKER_02 12:37

Um, and I don't always ask this question, but in this case I will. Any important family history of hereditary illnesses or not that she commented on.

SPEAKER_01 12:47

Um I didn't directly ask that question either. So another learning point for me.

SPEAKER_02 12:54

And on system inquiry, I think I've got a sense of her multi-systems, but then no rashes anywhere. No, no rashes. No no abdominal swellings or masses that she noticed. And she didn't feel any any sworn uh glands outside of her necks, within the groin or the armpits.

SPEAKER_00 13:10

No, nothing.

SPEAKER_02 13:11

No headaches.

SPEAKER_00 13:13

No.

SPEAKER_02 13:13

No change in sort of her thirst or peeing a lot or not so much.

SPEAKER_00 13:17

No.

SPEAKER_02 13:18

No. Uh, and you said no change in bowel habit. Alright. Um, let's kick let's examine this lady then. I'm quite intrigued. So on examination, what were her vital signs?

SPEAKER_01 13:29

So resp rate was 18.

SPEAKER_02 13:31

Normal.

SPEAKER_01 13:32

Saturations 99% on air.

SPEAKER_02 13:35

Normal.

SPEAKER_01 13:36

Blood pressure 104 over 70.

SPEAKER_02 13:39

Lowish.

SPEAKER_01 13:40

Mm-hmm. Heart rate 80.

SPEAKER_02 13:43

Normal.

SPEAKER_01 13:44

Temperature 35.4.

SPEAKER_02 13:48

Normal, low normal.

SPEAKER_01 13:49

And she was allergies, yes, it was 15 out of 50.

SPEAKER_02 13:53

Um, and okay, so where shall I start examining her chest first, please, because of this productive cough.

SPEAKER_01 14:00

Okay, so crackles throughout the left side of the chest.

SPEAKER_02 14:06

Okay.

SPEAKER_01 14:07

Right side was clear.

SPEAKER_02 14:09

Okay. Um, heart exam?

SPEAKER_01 14:12

Normal.

SPEAKER_02 14:13

Abdo.

SPEAKER_01 14:14

Abdo. Um slight liver edge. So uh yeah, three three centimeter liver edge palpable, non-tender.

SPEAKER_02 14:26

Hmm. Okay. Plubbing of the hands? No.

SPEAKER_01 14:32

Ooh, what are you thinking about there with the clubbing?

SPEAKER_02 14:34

Lung cancer.

SPEAKER_01 14:37

Okay, there was no plubbing.

SPEAKER_02 14:39

Okay. Um, and no splinter hemorrhages. No. No. All right then. And then um, what have I missed out here? And then let's have a feel of her neck and any any other sort of um nodes anywhere in the body.

SPEAKER_01 14:54

So, examination of the cervical lymph nodes. There were enlarged cervical lymph nodes, which were a little bit tender as well. There was a sub-mandibular lymph node palpable as well. There was no lymph nodes palpable in the supraclavicular region that would indicate Burkov's node. There was some lymph nodes palpable in the axilla, and there were also lymph nodes palpable in the groin bilaterally.

SPEAKER_02 15:19

Right. Okay. But you didn't feel a spleen, did you?

SPEAKER_01 15:23

No. Although I don't think I've ever felt a spleen. I find it really difficult to feel a spleen.

SPEAKER_02 15:29

You probably did when you're practicing for your paces.

SPEAKER_01 15:32

Yes, yeah.

SPEAKER_02 15:32

Um, and that you went to one of those courses. But yes, I know what you mean.

SPEAKER_01 15:35

It's really difficult to. Yeah, I'm sure I have, but yeah.

SPEAKER_02 15:40

So, all right, that's a lot of data. I think what I'm scribbling down now, I'm thinking about she's got good signs of a chest infection, possibly pneumonia. We'll do a chest x-ray and have a look at that. But in the background of this, we are looking at someone who has got some kind of indolent disease process going on, which has resulted in hepatomegaly, um, lymph nodes above and below the diaphragm, systemic features of weight loss and night sweats. Um uh, and and then, of course, there's the difficulty swallowing, which is affecting her oral intake and has led to 20 kilogram weight loss. So I am worried about malignancy. Um, so that's we're going to be screening for that. Why on earth should she have had dysphagia years ago, which went away on its own after a few months? I I can't quite make sense of that. For example, if she were to have, let's say, an esophageal cancer, which was causing um stricturing or or or narrowing of the esophagus, that doesn't go away and come back again. So that's odd. Um but in the first instance, I'd like to do some tests, and I've written down quite a lot here in the margin. So FBC use an E CRP. I also want thyroid, liver, and bone and a chest x-ray as well.

SPEAKER_01 16:58

Okay, so um I want to start with full blood count. So white cell, 20. Hi, okay. Neutrophils 18.

SPEAKER_02 17:08

Okay.

SPEAKER_01 17:09

HB, 90.

SPEAKER_02 17:12

Hello.

SPEAKER_01 17:13

Baitlets 444.

SPEAKER_02 17:15

Have you got an MCV?

SPEAKER_01 17:18

Not written down, I'm sorry.

SPEAKER_02 17:19

Okay.

SPEAKER_01 17:21

That would have been vitally important. I haven't written it down, which maybe means that it was normal because I normally urea, I know you don't look at this as two creatinine 34. What was her body habitus like?

SPEAKER_02 17:38

Just to sort of contextualize.

SPEAKER_01 17:40

Incredibly thin.

SPEAKER_02 17:42

So maybe that's that that creatures low because of her low muscle mass. So you said sarcopenic, right?

SPEAKER_01 17:47

Yeah, absolutely. Her sodium was one two eight. Oh, low. And on the bone profile, calcium was normal, but her alk foss was one eight one.

SPEAKER_02 18:02

Okay.

SPEAKER_01 18:03

So slightly higher. Bellareba was normal.

SPEAKER_02 18:06

Billy normal. Did you give her potassium? Sorry.

SPEAKER_01 18:09

Potassium, no, I didn't. I apologise. Potassium is five.

SPEAKER_02 18:12

So presumably normal. And thyroid function? Thyroid function was normal. Yep, okay, but that tails that theory off. Um good. Do we have a CRP?

SPEAKER_01 18:23

We do, is 198.

SPEAKER_02 18:26

Okie dokie, that's very high. And is there a chest x-ray, please?

SPEAKER_01 18:30

There's a chest x-ray, and the chest x-ray um on review showed widespread changes in the left side consistent with pneumonia. So consolidation on the left side.

SPEAKER_02 18:41

Okay, all right. Um, okay. Let me have a think. So if I was gonna write this as a post-it ward run note, I would write impression one, community acquired pneumonia. Not hypoxic. Curb 65 score is technically zero, so it could be ambulated with all antibiotics in this point of view. However, that that is not the only issue here. That's number one. Number two, hmm, what happened for number two? Um, mild uh hyponatremia um in the context of pneumonia and and euvlemic fluid status. Number three would be anemia, which presumably is new. And number four would be um I group together um hepatamegaly, widespread lymph adenopathy, night sweats, weight loss, um, query malignancy, query hematological, query TB, although I don't love that. And then my last one, I think I'm on number five, is recurrence of difficulty swallowing, which is impacting oral intake and has resulted in weight loss and her currently being clinically underweight, I think you said, right?

SPEAKER_01 19:59

Yeah, absolutely.

SPEAKER_02 20:00

How on earth do I put one to five together into one unifying diagnosis? I'm absolutely cannot force them in together at the moment. And maybe they don't want to be forced. Maybe that would be an unnatural forcing. But this is what I always say when I'm teaching doctors, I don't know what the answer is, but I sort of know what to do in the meantime.

SPEAKER_01 20:18

What do you want to do? So you've given me loads of diagnoses there. So you have to think about how you're gonna manage it, but also how you're gonna do investigations to decide which it is and which it isn't. So you've generated a beautiful hypothesis, but I need to know what you're gonna do next.

SPEAKER_02 20:34

So the first thing, which I you know, what we want to know is is she going home or not? So my first thing is plan one, admit. And here's my rationale for that. She does not need admitting just for the pneumonia, but I'm worried about the the sounds like an accelerated weight loss, and she doesn't have much weight left to lose. And if she's not comfortably eating or drinking, then um we might need to think about urgent inpatient investigation, so it should be an OGD and uh nutrition supplementation. One thing I didn't ask you at the beginning is this difficulty swallowing to fluids and solids?

SPEAKER_01 21:11

Solids only is painful. Fluids seem to go down okay. And interestingly, she said that solids give some relief.

SPEAKER_02 21:20

Can't make any sense of that. All right.

SPEAKER_01 21:23

No more either. That's why I say it was interesting. I was like, okay.

SPEAKER_02 21:27

No bells ringing over here.

SPEAKER_01 21:28

Okay.

SPEAKER_02 21:29

Um, so admit. Um that's number one. Number two, antibiotics. Um, do I need to cover for atypicals? I don't think so. As I say, it's curb zero. Um, so amoxicillin should be sufficient.

SPEAKER_01 21:44

Okay.

SPEAKER_02 21:44

That's the easy bit.

SPEAKER_01 21:46

IV or oral?

SPEAKER_02 21:49

A febrile, CRP 200, difficulty swallowing. We'll give them IV because they're big, aren't they?

SPEAKER_01 21:56

Amoxicillin.

SPEAKER_02 21:57

So struggle to choke them down.

SPEAKER_01 21:59

Yeah.

SPEAKER_02 22:00

Uh and chlorithromized another size of a thumb, they're a humongous. So um Ivy antibiotics, that's my two easy wins. Now, number three. I think inpatient OGD um gas slash gastro review to investigate um dysphagia, query mass effects slash stricturing as dysphagia to both liquid. Oh no, wait, liquid, just solids, you say, to to solids, but liquid still going down. That sort of fits with a with a throat that's slowly closing, doesn't it? Um and liquids can pass, but solids can't. Um number four, I'm up till now. Um pending the results of the OGD may potentially we'd have to go on on a what I would call a cancer hunt, and that might look like a PET CT, looking at lymph node avidity um and um considering a site for biopsy. So I think um we would do uh the routine, my routine blood tests for for hepatomegaly and lymph nodes which are infective screens. So I'm talking about EBV, CMV, HIV testing, all needs to be done. Um but if those are all negative, then we might be thinking about getting a PET CT to look for avidity and then thinking about biopsying um a useful lymph node to see whether there was a malignant process we need to look at. That could happen as an inpatient or under a two-week wait. But I'm minded to do the do the endoscopy first and just see if that actually shows us macroscopically a problem, which will help us direct the rest of our investigations.

SPEAKER_01 23:35

Um are there any blood tests that you would do to help indicate increased cell turnover within the body? That we could do quickly.

SPEAKER_02 23:45

Moving on to things like um uh my my general sort of hematological screen, um your LDH had to and your uh uh BT microcoblin as well would be useful. Would I speak to heme at this point? Anemia, so she's got one line down, she's got some B symptoms. Um I might have a conversation, a phone call with hematology and say, does this does this resonate with you? Uh and what would you do next? But I don't think I'd ask to kind of view the patient quite yet. Um, and I've got a feeling hematologist might say you need to treat the infective acute issue first of all, um, because that's going to muddy a lot of waters in terms of other tests that we are doing. Gosh, is that enough for today?

SPEAKER_01 24:37

It's complicated, isn't it? There's a lot going on here. And we've talked about is there one unifying diagnosis or is there two different diagnoses as good old Hickens dictum? Patients can have as many diseases as they done or please. So um, when I get a situation like this, what I do is what is the that is really complicated? What is the thing that is going to either result in this patient's death? What is the most serious thing that I need to rule out in this situation? So you've mentioned cancer, so yeah, is it cancer? Do you know, do we need to rule that out? And you've suggested some options there, like a PET CT, potentially um, doing that and some blood tests. And then I have a list of you mentioned um pneumonia, which we've talked about, you mentioned TB. Um what are you gonna do? Do you want me to tell you some results for the tests?

SPEAKER_02 25:33

I think you better have, because realistically, that would be my post-take wardrobe plan. And I'd say, and let's see again tomorrow.

SPEAKER_01 25:40

Excellent.

SPEAKER_02 25:41

Okay, and we'll have some results then. Yeah. And um I'll my my brain might have might have done something useful overnight while I was asleep and I thought of something in the morning. But um I I'm I'm I'm satisfied with my initial plan, which is admit, investigate, have a think, treat.

SPEAKER_01 25:57

And you've put it on antibiotics, haven't you? So you don't think there's anything else that we need to do at the moment? Okay, fine. So um the OGD was done that day, actually. Um, which was really incredible. And the report says there was widespread are you gonna guess what I'm gonna say? No, okay, okay. Widespread esophageal candidiasis.

SPEAKER_02 26:27

Candida, okay.

SPEAKER_01 26:29

Yeah. Um that was present all through the esophagus and actually quite high up as well, um, in in the pharynx, pharyngeal area. So does that change anything? I've given you one piece of information. You've had your diagnostic, your diagnoses. Does that help you confirm or refute any of the diagnoses that you had?

SPEAKER_02 26:52

So um you should not have uh widespread esophageal candida within a competent immune system if you have not been taking suppressants or steroids um uh or have possibly been null by mouth for a long period of time. People who have pegs um and don't use their mouth to take food, they can sometimes get um get candida as well. So I think in this case, I do need to know the results of the HIV screen. Um, and umatological disease still could be on it. I know that her white cells and neutral are up rather than depleted. Um, and she's got a good CRP response. So her immune system is working, um, but it doesn't completely take lymphoma or leukemia off the table. But I think our urgent result we want to get is the the HIV test, um, first of all, to make sure her immune system is working. Uh and then maybe a C the CT, as I mentioned, the CT, either PET or plain CT test abdopelvis looking for malignancy and the extent of the lymphedonopathy as well, because uh malignancy could do it as well.

SPEAKER_01 27:53

Okay. You mentioned HIV a few times. Why?

SPEAKER_02 27:57

Oh, because you want to make sure, well, HIV is a is a treatable reversible uh condition, but uh untreated, it results in um profound immunosuppression, um, which can result in uh making more predisposed to certain cancers and infections.

SPEAKER_01 28:11

Okay. Um so yeah, a HIV test was done and it was positive.

SPEAKER_02 28:16

Okay. Okay. So then of course we need to tell her, we need to involve the right people, initiate the right treatment. I mean to think about what behaviours or backgrounds or or risk profiles might have led to this diagnosis.

SPEAKER_01 28:33

Absolutely. Where does that shift your thought process in the diagnosis? What's the cause of her symptoms?

SPEAKER_02 28:43

Well, untreated HIV. We don't tend we tend to say uh advanced HIV rather than AIDS these days. Um so you I'd you call it advanced HIV. But of course, if you HIV, you are more likely to develop um some malignancies as well and lymphomas. So that still is potentially on the table. Um but I think in terms of the list of symptoms that I've made here, difficulty swallowing, candidiasis, productive cough, infection, weight loss due to poor intake due to candidiasis, night sweats. Okay, maybe HIV, but I I still I'm still keep hanging on to this potential, also having a hematological malignancy there. Amenorrhea, I honestly don't know if that if that's an association or not. Um but I think everything else can sort of sit under the HIV diagnosis, can't it?

SPEAKER_01 29:39

Okay, yeah, it can do. So could all of this be HOV? Um, could it be sero conversion? You know, you know, it's so many things that this could be. Um how so you've said you're gonna get in touch with somebody about the HIV diagnosis. You couldn't tell the patient, but what are you gonna do aside from that for the patient treatment-wise?

SPEAKER_02 30:06

Uh well, she needs to have her HIV status quantified. So we're talking about CD fall count, um, the uh viral load as well. Um, and someone needs to come and speak to her, and it's not be me about starting antiretroviral therapy. Um I I I keep saying it, I'm I would still do a CT uh chest abdopelvis because I want to make sure there's not additional either disseminated infection or disseminated malignancy associated with this as well. Um do I think she's got TB with all of this? TB doesn't usually cause just consolidation and a high CRP on X-ray. You normally get sort of apical shadowing. But I think we now need to put her into a side room and get some sample, three samples of a student for acid fast bacilli just to make sure she doesn't have pulmonary TB if her immune system is a significantly impaired. Yeah. That's what I'd do.

SPEAKER_01 31:01

How would you treat the thrush?

SPEAKER_02 31:04

Yeah, so nice that probably is not going to penetrate enough. So we're talking about fluconazole, which you can give IV after you check they've got a normal QTC interval on their ECG. Um, and also they're not on any other medications that can interact with fluconazole because it does something funny to your uh to your uh cytochrome fever. I can't remember if it inhibits or it induces it. But um that yeah, so you I I probably would start um systemic antifungal treatment.

SPEAKER_01 31:31

Okay. So she did have a C T thorax abdopelvis. And the C T thorax abdopelvis revealed no evidence of malignancy that was possible, but did show findings suggestive of TB.

SPEAKER_02 31:45

Oh, you know, I said that right at the beginning, didn't I? I did more than anything else.

SPEAKER_01 31:48

You did you did say that right at the beginning. Um, how could we piece all this together?

SPEAKER_02 31:57

Um, the the likely sequence of events is is HIV infection. She serious converted a while ago, it was left untreated, um, and then she developed um a significant immunocompromise, which led to the candida. That in turn led to the dysphagia. The weight loss was contributed to by the dysphagia and the untreated infection as well, and the TB, which they used to call consumption in the old days, because it's a consumptive disease, it consumes the body and it makes you lose a lot of weight and become very frail. Um, we do need to think about how she managed to do this. So, what in her background um led her to get HIV and TB, because we want to make sure that she's safe and healthy moving forward when she stabilised both on antiretroviral treatment, but also on anti-TB treatment, and she'll be on significant medications for that for many, many months to check she has a response to it.

SPEAKER_01 32:50

Yeah. And that was when I saw her in the acute setting, that wasn't a conversation that I had at that time. Um I I'm not sure whether I should have done or not. Um, it didn't feel it was the right time to have that conversation the first time I met it, if I'm being honest. Um, so I didn't, but I know that somebody did have that conversation with her. Um, because that's obviously incredibly important to have. Um the amenorrhea as well, just to touch on that.

SPEAKER_02 33:21

Yeah, tell me about that, because I can't make sense of that one. Yeah, is that just because oh low body habit is maybe low BMI? Yeah, yeah.

SPEAKER_01 33:27

Absolutely. Of course, of course. So, you know, such huge amounts of weight loss. Um, you don't have the body fat, uh, but you need to menstruate, um, which is why you sometimes see amenrhea in um individuals who have uh eating disorders um as well. So that could be.

SPEAKER_02 33:45

No, I should have picked that up. Yeah.

SPEAKER_01 33:46

Yeah, yeah. Although um you don't want to assume it's that and it might be something that you look at um a little bit down the line, if she has gained weight and she still doesn't have periods, do we need to think about hormonal tests, FSH to identify if she is in the menopausal state? And will she need HRT, for example, or does she want HRT? And that's certainly something that we need to think about. Yeah. Yeah.

SPEAKER_02 34:10

Um, any updates? How is she doing?

SPEAKER_01 34:13

So the last um it was doing about it was a long time ago, and I was spending about 18 months ago now. Um, she was okay.

unknown 34:23

Okay.

SPEAKER_02 34:23

Okay.

SPEAKER_01 34:24

Yeah.

SPEAKER_02 34:24

Okay.

SPEAKER_00 34:25

Um, but I don't know any more information than that.

SPEAKER_02 34:30

Um so I think that was I enjoyed uh using my mental muscles on that case and and figuring it out. And you know what just confirms to me, I cannot think without a pen and paper. Like I just weird.

SPEAKER_01 34:45

Even then I was writing things down, and um yeah, and even though I know the case, I was still finding it incredibly helpful to write things down. So you know when we type on a computer, it's not the same, it's not the same, is it? So is our thought process different? Do we reason differently, clinically reason differently, with a pen and a paper than we do with a type of typewriter?

SPEAKER_02 35:08

A typewriter, all right, you know that old. Um but when you're typing, you have to type one thing below the other in a in a in a vertical line. Whereas a paper, you can go left, right up, down the margin, create a little bubble, a balloon, a diagram, an offshoot, and an arrow. I've actually drawn here on the paper, old school, a pair of lungs with some exercise.

SPEAKER_01 35:25

Show me, show me.

SPEAKER_02 35:26

But the crackles. Can you see my lungs? Oh, it's a bit it's gone blurred. It's got my blur on it. And then I drew a little abdomen with an arrow through it for her abdo as well. Yeah because that's how I learned to do it when I first started using it.

SPEAKER_03 35:39

Retro, isn't it?

SPEAKER_02 35:40

And so when I get them interaction, I I go back to what I know.

SPEAKER_01 35:44

Yeah. So I mean, I think that case for me um highlights, and it's something that I don't think we talked about much on the podcast before, actually, is the importance of thinking about HIV as a diagnosis, and that anyone and everyone can have HIV, and it's something that we need to think about. And I know there's a lot of guidance now um regarding who to test and when to test. You know, in in my old hospital, we would do it in AE, and then everybody would have a test, but they would then opt out of the test um if they didn't want it. So um, and I read an incredible book for people who um enjoy reading called And the Band Played On. And it is a non-fiction story about HIV and as it was called then, um, acquired immune deficiency syndrome, um, about where it started, um, about the history in America and and Africa. It's just such a good book. Um, fascinating. It's huge, it's very thick. Took me a long time to read, but very, very good if anybody's interested in reading a bit more about it.

SPEAKER_02 36:53

I think I've heard of it.

SPEAKER_01 36:54

It's so good. They made a film as well of it, which I haven't watched, but the book is incredibly good.

SPEAKER_02 36:58

So I'm thinking of the film, yeah.

SPEAKER_01 37:00

Yeah, I certainly think we need to think about HIV more. I have had patients who have had a positive test and they're in their 80s. So I don't think age shouldn't be a barrier um to doing HIV tests. And I think sometimes we're like, oh, they're 80, they're not gonna have HIV, but actually they can still have HIV.

SPEAKER_02 37:19

So um I remember when I was younger and you had to get consent for HIV tests. You didn't consent for an FBC or a CRP, but eight or even hepat B, another bloodborne virus. But you had to get patient consent for HIV, and that obviously was just a human factor sticking point of doing the test because busy people didn't have time to go and consent everybody for one specific blood test. Um, and then it changed, as you say, it changed to an opt-out system where but I I don't know how that was enforced, but there posters up saying you will get an HIV test part of our routine blood. If you don't want one, let us know. I don't know, but but but I I now work in a hospital where everyone gets one um on admission. Um, and I think you know, in terms of economic uh and uh medical uh balance, even if you pick up two or three new HIV cases a year, it pays for itself and the makes the resources completely worthwhile doing for all the extra tests that you're doing. So it's actually borne out to be a very, very useful approach, I think.

SPEAKER_01 38:19

Yeah, absolutely. So I hope everybody's listening learned something from that. Um is an interesting case, and it was what I really loved is actually watching Ben's facial expressions as he figures out what's going on throughout the case. Um, and I think the dysphagia, when I hear you dysphagia, I automatically think esophageal cancer straight away.

SPEAKER_02 38:40

Um cancer or candida?

SPEAKER_01 38:42

Cancer, esophageal cancer, sorry, yeah, not candida, I was thinking cancer. Um so I wonder if that that's a red herring, it's sort of that anchoring bias, isn't it? And that was certainly where I went initially with this case, is that I was like, oh, difficulty swallowing weight loss, oh gosh, he's got cancer, this is going to be awful. Um, and yes, it was it was very sad as you had us um lots of things going on, but it the end diagnosis was so far away from what I initially thought. So, how things change over time.

SPEAKER_02 39:12

And is that what she said about solids being it's what she said is sort of helped. Is that is that something with I know liquids?

SPEAKER_01 39:19

She said liquids helped. So I don't know whether I have no idea whether I my thought process was is that because it eases the candida, the thrush, does it make it fit a bit? I'm not sure.

SPEAKER_02 39:30

Okay, okay, thank you very much.

SPEAKER_01 39:34

Thank you to all of our listeners out there. Please rate to review and subscribe to the podcast. We absolutely love doing this, and it's amazing to have um so many listeners now. Me and Ben are setting up um the Home of Medicine Pods Instagram account. We're gonna trial it anyway, always see how we get on with it. Um, so any feedback would be great, and please email us because we love hearing from you. Thank you so much. Thank you, Ben, as always.

SPEAKER_02 40:03

See you later.

SPEAKER_01 40:04

Thanks for listening. Goodbye.

SPEAKER_02 40:06

Bye.