A member presented a medical case:
Ischemic colitis, coronary artery spasms, and asthma all diagnosed within one year in a 54 year-old.
54 year-old woman with a history of migraines and Raynaud, gets diagnosed with ischemic colitis, coronary artery spasms, and asthma during the past year, and wonders if they are all related, and what sort of treatment plan is best.
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Patient demographics
Gender
Age
54
Ethnicity
White or Caucasian
Occupation
psychiatric social worker
Chief complaint or problem to solve
In 2015 I was diagnosed with chronic obstructive asthma, coronary artery spasms, a pulmonary embolism (due to being on HRT) and ischemic colitis. What is going on with my body? Why all of this in 2015?
Case history
I was diagnosed with migraines in 2005. They became severe in 2010 and in Sept 2013 I was treated for them at The Cleveland Clinic's IMATCH Program.In Jan, 2014 I was diagnosed with Raynauds. In Feb 2015 I developed asthma after a bad cold and was hospitalized for it in June. I was on prednisone almost every week. In May 2015 I was diagnosed with coronary artery spasms which I get about 1x month - the last two were triggered by spirometry/PFT. Over Labor Day weekend, I got shortness of breath/dizziness which was originally misdiagnosed as asthma/then correctly diagnosed as a small PE. Treated with Xarelto. Following that I got severe abdominal pain (worse after eating), rectal bleeding,nausea which was diagnosed as ischemic colitis. This has never really gotten better. I have lost about 6 lbs., my diet is pretty much limited to yogurt and cous-cous, I am extremely fatigued, I have recurrences of the rectal bleeding. My pulmonologist stopped the Xarelto in response to my last episode of rectal bleeding (11/6 - 11/8) which lasted for 3 days and appeared to be of a large volume.

PMH: Severe and chronic migraines. Raynaud's Syndrome.GERD
Meds: Pristiq; Naproxen;Toprimate;Omeprazole;Nifedipine;Symbicort;Montelukast:Proair;Spiriva;Nebulizer;Allegra;Calcium/VitaminD;Magnesium;CoenzymeQ10;Butterbur;Riboflavion;Probiotic; Zofran
Allergies:Penicillin;Levaquin;Cipro;sensitivity to Benadryl; dust mites, dogs, cats, trees, grass, mold
Other tests: 10/29/15: CBC & D-Dimer - normal. May, 2015 echostress, normal 9/4/15: ultrasound of legs: normal & cardiac echo - normal 10/23/15 pulmonary function testing - inconclusive due to having a coronary artery spasm in the middle of it. ABG - normal
Xrays: 9/3/15: CT scan of chest w/ contrast small peripheral PE in lower right lobe, 8/2014; Colonoscopy - normal
Procedures:
Purpose of case discussion
Diagnostic dilemma: "What are the next steps for evaluation?"
Supplemental Materials

Dr. John Goldman
Internal Medicine - Rheumatology
3 doctors agree

In brief: Need to follow data

For this case we need to know the ANA and subsets, cardiolipins, lupus anticoagulant, Beta 2 glycoprotein but I would have expected that the workup at Cleveland Clinic would have covered this if you saw a rheumatologist.

In brief: Need to follow data

For this case we need to know the ANA and subsets, cardiolipins, lupus anticoagulant, Beta 2 glycoprotein but I would have expected that the workup at Cleveland Clinic would have covered this if you saw a rheumatologist.
Dr. John Goldman
Dr. John Goldman
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Dr. John Chiu
Internal Medicine - Allergy & Immunology
4 doctors agree

In brief: Complex issue

With so many complications and disease conditions, you will likely benefit from a team approach.
For that I would recommend that you go the something like the Mayo Clinic.

In brief: Complex issue

With so many complications and disease conditions, you will likely benefit from a team approach.
For that I would recommend that you go the something like the Mayo Clinic.
Dr. John Chiu
Dr. John Chiu
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Dr. Djamchid Lotfi
Neurology
1 doctor agrees

In brief: Connective tissue disorder ?

Multisystem disordersand conditions like connective tissue or collagen vascular disease come to mind A good internist should be able to do the right investigations (e.
g. circulating antibodies, vasculitis etc) and connect the dots?!

In brief: Connective tissue disorder ?

Multisystem disordersand conditions like connective tissue or collagen vascular disease come to mind A good internist should be able to do the right investigations (e.
g. circulating antibodies, vasculitis etc) and connect the dots?!
Dr. Djamchid Lotfi
Dr. Djamchid Lotfi
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Dr. Pierre Moeser
Internal Medicine - Rheumatology
1 doctor agrees

In brief: No unifying Dx

Though there is a component of spasm in several of these diagnoses, there is no single unifying diagnosis.
However, anxiety in general or anxiety about having these problems can worsen the Raynaud's, the migraines, and the asthma. I would consider meditation, approved herbal supplements, etc. to calm oneself. Of course, ischemic colitis and coronary spasm need traditional intervention & treatment.

In brief: No unifying Dx

Though there is a component of spasm in several of these diagnoses, there is no single unifying diagnosis.
However, anxiety in general or anxiety about having these problems can worsen the Raynaud's, the migraines, and the asthma. I would consider meditation, approved herbal supplements, etc. to calm oneself. Of course, ischemic colitis and coronary spasm need traditional intervention & treatment.
Dr. Pierre Moeser
Dr. Pierre Moeser
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1 comment
Dr. Mohamed Aboyoussef
search for a systemic CTD or vasculitis
Dr. Edgar Mendizabal
Internal Medicine
1 doctor agrees

In brief: Probably not

related strictly speaking. You will need several treatments

In brief: Probably not

related strictly speaking. You will need several treatments
Dr. Edgar Mendizabal
Dr. Edgar Mendizabal
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Dr. Nassir Azimi
Interventional Cardiology

In brief: Review meds

First thing to do is review all the medications and potential side effects.

In brief: Review meds

First thing to do is review all the medications and potential side effects.
Dr. Nassir Azimi
Dr. Nassir Azimi
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Dr. Diane Stein
Pediatrics - Neurology

In brief: Autoimmune evaluation

I do not know enough to offer a diagnosis, however I recommend an autoimmune evaluation.
When your immune system starts treating normal parts of you as if they are "foreign" or like an infection, the symptoms are as varied as our body organs. The symptoms or "disorder" depends on which protein or organ is targeted. All of the symptoms you describe are part of an autoimmune picture (but none are diagnostic of immune issue all by themselves.)

In brief: Autoimmune evaluation

I do not know enough to offer a diagnosis, however I recommend an autoimmune evaluation.
When your immune system starts treating normal parts of you as if they are "foreign" or like an infection, the symptoms are as varied as our body organs. The symptoms or "disorder" depends on which protein or organ is targeted. All of the symptoms you describe are part of an autoimmune picture (but none are diagnostic of immune issue all by themselves.)
Dr. Diane Stein
Dr. Diane Stein
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Dr. Tracie Leonhardt
Emergency Medicine

In brief: Multiple issues

I would look for the core.
Go back to basics in the physiology instead of looking for just the diagnosis. All of these are part of an inflammatory cascade - so look for the source of the inflammation and trigger. Look for the inflammatory cytokines and markers. Coagulation markers and see if they are abnormal. These may give you an indication of where to look for a source. I find in many of these cases going back for a really good history of exposures, travel, GI issues helps a lot. When there are a lot of allergy issues I always evaluate the GI system and do a comprehensive digestive stool analysis to check for inflammation and infections. You can also check the patients IGG, IGM and IGA to see if the immune system has been compromised with secondary immune deficiency. Primary would be unusual if he has not been ill most of his life.

In brief: Multiple issues

I would look for the core.
Go back to basics in the physiology instead of looking for just the diagnosis. All of these are part of an inflammatory cascade - so look for the source of the inflammation and trigger. Look for the inflammatory cytokines and markers. Coagulation markers and see if they are abnormal. These may give you an indication of where to look for a source. I find in many of these cases going back for a really good history of exposures, travel, GI issues helps a lot. When there are a lot of allergy issues I always evaluate the GI system and do a comprehensive digestive stool analysis to check for inflammation and infections. You can also check the patients IGG, IGM and IGA to see if the immune system has been compromised with secondary immune deficiency. Primary would be unusual if he has not been ill most of his life.
Dr. Tracie Leonhardt
Dr. Tracie Leonhardt
Thank
Dr. Harinder Gill
Internal Medicine - Cardiology

In brief: Complex case

assuming that all pertinent positive AND negative lab data has been presented there is no single diagnostic entity that readily fits your constellation of signs and symptoms.
On what basis is the diagnosis of "coronary spasms"? Hace you been tested for thrombophilia?Might you have a one of the vasulitidies?conective tissue disease? A paraneoplastic syndrome? Not being on anticoagulation after an occult PE is very problematic;how about a caval filter? On what basis the diagnosis of ischaemic colitis? What are the specific indications for teach of the medications you are on, are they still needed? .And so on,many questions needing answers and a review of all of the existing primary clinical ,lab & imaging data before a specific diagnosis or diagnoses are rendered.Good Luck.

In brief: Complex case

assuming that all pertinent positive AND negative lab data has been presented there is no single diagnostic entity that readily fits your constellation of signs and symptoms.
On what basis is the diagnosis of "coronary spasms"? Hace you been tested for thrombophilia?Might you have a one of the vasulitidies?conective tissue disease? A paraneoplastic syndrome? Not being on anticoagulation after an occult PE is very problematic;how about a caval filter? On what basis the diagnosis of ischaemic colitis? What are the specific indications for teach of the medications you are on, are they still needed? .And so on,many questions needing answers and a review of all of the existing primary clinical ,lab & imaging data before a specific diagnosis or diagnoses are rendered.Good Luck.
Dr. Harinder Gill
Dr. Harinder Gill
Thank
Dr. Amrita Dosanjh
Pediatrics - Pulmonology

In brief: Mgt

I would suggest better control of your pulmonary symptoms with a review of possible allergic triggers and consideration of adding Singulair.
If you take a puff of Albuterol or Xopenex, (levalbuterol) does it relieve your shortness of breath? Have you ever had wheezing. PE is an important consideration, and if you are short of breath, I would suggest a Cardiac Echo holter to detect irregular heart rthyms and another HRCT.

In brief: Mgt

I would suggest better control of your pulmonary symptoms with a review of possible allergic triggers and consideration of adding Singulair.
If you take a puff of Albuterol or Xopenex, (levalbuterol) does it relieve your shortness of breath? Have you ever had wheezing. PE is an important consideration, and if you are short of breath, I would suggest a Cardiac Echo holter to detect irregular heart rthyms and another HRCT.
Dr. Amrita Dosanjh
Dr. Amrita Dosanjh
Thank
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