I am thrilled to be blogging for the KAFP.  I would like to use this blog as an exchange of clinical conundrums, updates and stories among all Kentucky family physicians.   I’ll post experiences from my practice under those headings and hope that you’ll read, contemplate and write in with your own ideas.

Here’s a case I’ve been struggling with for three years……

White Female, age 41

PMHx:

  • Hashimoto Thyroiditis
  • Diabetes Type II
  • NASH with cirrhosis (biopsy proven)
  • Crohn’s (biopsy proven)
  • Thrombocytopenia
  • Obesity (weight 190, height 54″)
  • Hyperlipidemia
  • Iron deficiency (but no anemia)

Meds:

  • Levothyroxine 600 mcg daily
  • Levemir 150 units twice daily
  • Novolog sliding scale
  • Lipitor 40 mg daily
  • Lisinopril 2.5 mg daily

Most recent labs (this month)

  • a1c 10.1
  • TSH: 0.88
  • LDL: 57
  • HDL: 47
  • TG: 127
  • microalbumin ratio: 13
  • AST/ALT 22/21
  • INR 1.0
  • Albumin 4.3
  • T. Bili 0.3
  • Iron % Sat 9
  • Hgb 12.0
  • MCV 90
  • Platelets 78K
  • She has previously had negative ANA titers, RF and anti-CCP antibodies.

Social History

  • Married, 2 children (and 2 step children)
  • Operates a foundary furnace
  • No tobacco Use
  • No alcohol use

I referred her to two different rheumatologists who do not think she has an auto immune problem because her titers are negative and she does not have findings of arthritis.

I referred her to an endocrinologist who told her to lose weight.

I referred her to hematology who said that her thrombocytopenia was idiopathic and to do nothing

I referred her to GI — they did the liver biopsy and told her to lose weight

Here is my clinical dilemma:

On her most recent visit (yesterday) — she now has a petechial (non blanchable) rash on her shins that itches and burns when exposed to hot water.   I am concerned that she now also has a vasculitis — and will likely do a punch biopsy at her next visit.

I feel very strongly that this patient has a complex autoimmune problem and may benefit from a systemic immunomodulator therapy — or at least have a unifying diagnosis for all of these issues that seem to be auto-immune related.  Unfortunately I cannot find a specialist who seems to be willing to look at the whole picture in the same way that I do……ANY THOUGHTS?

Also……do you have any patients who require SO MUCH thyroid hormone replacement and insulin? 

Write in and give me your thoughts!

Dr. Z.