Presidential Pathology

In honor of election season, let’s review some pearls and boards material surrounding our nation’s presidents!

Woodrow Wilson – Influenza, Stroke

1918: There is some suspicion that President Wilson caught the famous virus from the 1918 flu pandemic. He later suffered a TIA and a massive stroke (L hemiplegia) – his staff hid the severity of his stroke while his wife supervised his duties.

Influenza:

·      Antigenic drift = small mutations that create different seasonal flus

·      Antigenic shift = switches species

·      Tamiflu = all hospitalized & high risk patients ASAP, low risk patients within 48hrs

o   Tamiflu debate, click here

Stroke:

·      Highest risk of stroke after TIA = 48hrs

·      Blood pressure goals:

o   Ischemic stroke, TPA eligible = Keep below 185/110

o   Ischemic stroke, no TPA = 220/120

·      TPA to be given within 4.5 hours

FDR – Polio

1933-1945: Photographers avoided taking pictures of FDR while he was in his wheelchair as it was viewed as a sign of weakness. Photos of him were deliberately taken only while the president was in a car or behind a desk.

Polio

·      The WHO anticipated eradicating polio from the planet by 2023. However, President Trump’s withdrawal from the organization had led to a severe decrease in funding and that may need to be reconsidered. Check out this clip from Sunday’s Last Week Tonight With John Oliver to learn more.

Eisenhower – MI, Crohn’s Disease

1955: He stayed in Fitzsimons Army Hospital in Colorado for 7 weeks after his heart attack, but I couldn’t find how they treated it. Just a few months later, six months prior to his next election, he was diagnosed with Crohn’s Disease and required surgery. He went on to win the election.

MI: Lysis vs Cath

·      Lysis if PCI cannot be performed in the “appropriate timeframes” below

·      PCI timeframes:

o   AMI within 2hrs = PCI in 60 minutes

o   AMI within 2-3hrs = PCI in 60-120 minutes

o   AMI within 3-12hrs = PCI in 120 minutes

Crohn’s Disease

·      Typically 2nd/3rd decade of life, male, hx of IBD in the family

·      Any part of the digestive tract from mouth to anus

·      Skip lesions

·      Full thickness inflammation (unlike UC = epithelial layer only)

Jed Bartlet – Multiple Sclerosis

2000: Widely acclaimed as the greatest president of our time, the Bartlet Whitehouse was rocked by scandal and outrage when it was revealed that the president and members of his administration had willfully omitted knowledge of the president’s devastating demyelinating disease. Despite the controversy, Americans saw past this lapse of judgement and reelected President Bartlet for a second term.

MS

·      Autoimmune, more in females, connected to psoriasis and thyroid disease

·      Internuclear ophthalmoplegia = difficulty adducting eye = pathognomonic

·      LP = Oligoclonal bands & IgG in the CSF

·      MRI = optic nerve lesions, juxtacortical lesions, and Dawson Fingers

·      Steroids for flares (inpt or outpt)

George W. Bush – Colonoscopy

2002, 2007: Colonoscopies aren’t that interesting but Bush did, indeed, hand over the power of the presidency to Dick Cheney on two occasions, each lasting just over 2hrs while he had routine colonoscopies.

Colonoscopy

·      Q10yrs, starting at age 50 (unless family hx, familial adenomatous polyposis, etc.)

·      Complications:

o   Pyogenic liver abscess

o   Infection

o   Bleeding (post-polypectomy, 1 week after procedure)

o   Perforation

o   Post-polypectomy syndrome: peritonitis without perforation after a transmural burn in the colon

Kennedy – Addison’s Disease

1961-1963: It looks like JFK suffered from quite a number of medical problems: chronic back pain, colitis, UTI, abscess, possibly malaria, and apparently was on a brief course of antipsychotics after a change in mood when he started some antihistamines. The most famous of these maladies was his Addison’s Disease, for which he was on daily steroids.

Interestingly, Kennedy was wearing his back brace on the day he was assassinated, which kept his posture fully upright in the limousine prior to getting shot.

Addison’s Disease:

·      Chronic adrenal insufficiency, autoimmune – patient’s on chronic steroids

·      Hyperpigmentation

·      Must be distinguished from acute adrenal insufficiency:

o   Look for hyponatremia and hyperkalemia (low aldosterone)

o   Hypoglycemia

o   Refractory hypotension

o   Hydrocortisone 100mg IV

REFERENCES:

https://www.cnn.com/2020/10/07/health/us-presidents-health-problems-wellness/index.html

https://www.healthline.com/health/diseases-of-presidents

https://www.ahajournals.org/doi/10.1161/STR.0000000000000211

https://text-message.blogs.archives.gov/2016/09/22/heart-attack-strikes-ike-president-eisenhowers-1955-medical-emergency-in-colorado/

http://www.emdocs.net/multiple-sclerosis-ed-pearls-pitfalls/

https://www.businessinsider.com/25th-amendment-colon-trump-reagan-bush-unfit-president-2017-10

http://www.emdocs.net/post-colonoscopy-complications/

peerix.acep.org

Case

76M pmh alcoholic cirrhosis, COPD presenting with altered mental status, vomiting, and diarrhea. Pt has been on a 3-day cocaine binge with increasing confusion and decreased oral intake. No fevers/chills, hematemesis.

Pt is hypotensive 80/40s despite 1 L. Pt is awake and alert but confused, aox0. Pt hypoglycemic to 45, received D50 with no improvement. K 2.8 but all other labs were normal. 

Pt was started on pressors but no significant improvement in BP.  The patient’s family stated said that the patient is in an out of hospitals for COPD and was recently discharged and has not been able to take his steroids.

The patient was treated with IV hydrocortisone for presumed adrenal crisis and admitted to MICU.  The patient’s mental status gradually improved after a few hours with resolving hypotension and was discharged the next day completely well.

Background

Adrenal glands produced mineralocorticoids, glucocorticoids, and androgens

Adrenal insufficiency affects 1-4/100,000 in the US, 80% from primary addison’s disease, other causes are trauma, drugs, infections, genetic disorders, sudden termination of prolonged glucocorticoid therapy, and pituitary disease (brain tumor/necrosis)

Adrenal insufficiency is extremely difficult to diagnosed in the ED, 44% of cases are diagnosed only after presenting in adrenal crisis

Stressors likely infection, surgery, trauma, emotional stress can exacerbate adrenal insufficiency

Presentation

Insufficiency: general dehydration, weakness, lethargy, AMS, delirium flank/back/abd pain, nausea, vomiting diarrhea, anorexia

Crisis: severe hypotension refractory to IV fluid and vasopressors

Diagnostic Studies

There are no great studies for adrenal insufficiency in the ED, random cortisol levels should not be drawn routinely, cortisol > 34 mcg/dL exclude adrenal crisis and < 15 is suggestive but this test is dependent on the patient’s corticosteroid binding globulin so free cortisol levels are very unreliable

Imaging in the ED is generally not necessary but if there are headaches suggestive of pituitary gland tumor or abdominal pain suggestive of secondary adrenal insufficiency, CTH and CTAP are options that can be used.

Treatment

If adrenal crisis is suspected, steroid should be given

Hydrocortisone 100 IV then 100 mg IV q 8h until acute crisis resolves, usually pt’s hypotension and clinical symptoms improves 1-2hrs after administration of hydrocortisone

50 mg for children 3-12 yo

25 mg IV for children < 3 yo

IVF up to 2-3 L

D5NS can be used as well for hypoglycemia, d50 for severe hypoglycemia

Vasopressors can be used but the patients are often unresponsive

Disposition

Admit to MICU for adrenal crisis

If patient is well appearing and just having weakness or fatigue, the patient can be discharged with followup with an endocrinologist/PMD who can do a normal serum cortisol level and ACTH stimulation tests as well as other extensive testing.

Steroid tapers for chronic steroid users I unfortunately there isn’t an optimal regimen verified by studies

For patients with short term glucocorticoid therapy (less than 3 weeks), you just stop and no taper needs to be given

For more chronic glucocorticoid therapy, it will depend on the dose the patient has been on, infection risk, duration of previous use, danger of underlying illness:

              Taper 5-10 mg/d every week from an initial dose > 40 mg prednisone or equivalent/day

              Taper 5 mg/d every week at prednisone doses 40-20 mg/d

              Taper 2.5 mg/d every two weeks at prednisone 20-10mg/d

              Taper 1 mg/d every 2 weeks at prednisone 10-5 mg/d

Generally we will only give 1-2 week course of medications from the ED, so make sure to do the calculations and give endocrine follow-up

Takeaways

For patients who are chronically on steroids often times for COPD, rheumatoid arthritis, crohn’s, etc. ask when the last time the patient had steroids; the patient might benefit from a steroid taper to prevent withdrawal.

Adrenal crisis is extremely rare and one should not wait for cortisol levels for a patient who is hypotensive and non-responsive to IVF/pressors. (often times, it’s just going to be that septic old patient that comes in with no clear history that’s unresponsive to pressors)