Dupilumab And Its Growing Pains

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Dupilumab And Its Growing Pains - Page #3

Lab Studies: Complete Blood Count with differential was within normal limits, without leukocytosis or eosinophilia. C-Reactive Protein was within normal limits. Other Studies: Electromyography (EMG) and nerve conduction studies (NCS) showed no neurogenic disease. X-ray of shoulder showed no osseous abnormality. MRI of the brachial plexus with TOS protocol showed normal signaling of the brachial plexus in all positions. Magnetic Resonance Angiography (MRA) of the chest with and without contrast showed no obvious structural compression of the subclavian artery or brachial plexus. Case Photo #1 Venous duplex was normal. However, arterial duplex demonstrated > 50% stenosis (with a 3:1 ratio in flow velocity) in the left subclavian artery provoked at 180 degrees of abduction, consistent with arterial Thoracic Outlet Syndrome. After further review with our radiologist, the left subclavian appears slightly more narrowed (red bracket) compared to the right subclavian in the MRA images obtained with elevation of the arms. Case Photo #2 Consultations: The patient was referred to a sports medicine specialist, who ordered an X-Ray, MRI, MRA, and venous/arterial duplex, while making referrals for the patient to see a neurologist and a vascular surgeon. A neurologist ordered and reviewed the EMG and NCS and concluded there were no signs of neurogenic TOS. A vascular surgeon reviewed the MRA, venous duplex, and arterial duplex. The patient also followed with his dermatologist, who recommended that the patient stop dupilumab while making a referral for the patient to see a rheumatologist. A dermato-rheumatologist (dual-certified) concluded that the patient's symptoms were inconsistent with the classic presentation of dupilumab-associated joint pain. The patient established care with a chronic pain specialist. Click here to continue. Challenge yourself by writing down a revised, working diagnosis before moving to the next slide.		Back
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