So the feedback from my last post was that we all love cases – and I have lots of them. So I am going to discuss two more cases that I have done laboratory consultation on, one of which has a … well just read and you’ll see.
Case #1: 48 year old male presented to outpatient clinic which a primary complaint of depression. He has been seen for the same issue 4 times before. At the first visit for depression he was started on one antidepressant, Lexapro, but within a few days starting having massive side effects and the medication was having no affect on his depressive symptoms. He was switched to Zoloft at his next visit, yet starting having the same response. On the third visit he was switched to Celexa, but yet still had a reaction. So you might be wondering what kind of reactions or side effects could he have had? Have you ever seen a drug commercial and they list all of the possible side effects and the list takes 30 seconds of the 40 second commercial? Um … he had all of them except for death. But if you couple all of these side effects with the depression, it was leaving him in a pretty rough spot. So his physician came to me for a consultation. He knew there had to be some reason that 1) none of the medications were working, and 2) the patient was having all of these side effects. The physician wanted to know if I had any ideas because he was out of options. I told him the patient was likely a high metabolizer of SSRI’s (the type of medication that all of the antidepressants he had prescribed fall into) and pharmacogenomic testing of the patient’s CYP2C19 and CYP2D6 alleles would verify that. So … the physician must have thought I was speaking Greek or Latin or something because he looked at me like I had two heads and was like “What?”. So I then explained about pharmacogenomic testing and high, intermediate, low, and non-metabolizers [for the muggles reading this blog: this type of testing is looking a your genes to see if and how your body breaks down the medications to use and can explain if a medication works or not or even the probability of having side effects]. So the physician was willing to try and we sent out the testing. Sure enough, the patient was a high metabolizer for both genes indicating that his body was essentially burning through the extended release capsules so fast the he was getting hit with all of the side effects that would not happen if his body metabolized it over the course of 24 hours. So any medication whose metabolism is regulated by these two genes would have the same issues in this patient. The physician then decided to try an antidepressant that wasn’t metabolized by either of genes, trazodone, and the patient finally received relief from his depressive symptoms without the massive side effects.
Case #2: An 84 year old female was in a car accident that resulted in multiple contusions and fractures. While in the ER she was also complaining of chest pain (couldn’t be because she had multiple rib fractures, huh?). The ER physician orders a D-Dimer in an attempt to rule out pulmonary embolism [aka blood clot in the lung for the muggles]. Ummmm … soooooooo … if a D-Dimer is negative it generally rules out pulmonary embolism but if it is positive then more studies need to be done to make the diagnosis. BUT … (yeah, there’s a big ole’ fat but) … D-Dimer is positive when there is any greater than normal clotting processes going on like blood clots, pregnancy, surgery, and TRAUMA. So this patient is covered in bruises and has multiple fractures so what do you think the result of the D-Dimer is going be? Any guesses? So, yes, the D-Dimer was positive. The physician then proceeds to order a work-up and treatment for … can you guess? Pulmonary embolism. Yes, my friends, he did. 1) He ordered the wrong test. There was no reason to order a test that, given the patient’s current condition, was not going to give him any reliable clinical information. 2) He failed to take into account the patient’s presentation, or didn’t know how to correctly interpret, the D-Dimer result. 3) He began treatment for a condition the patient didn’t have. I was brought in on the case when I was reviewing the previous day’s critical values (all positive D-Dimers are critical values in this facility). I saw this critical value and began looking in the EMR to see if appropriate action was taken by the ER physician and that’s when I was like “What the H E double-hockey sticks?” That’s when I talked to the patient’s attending physician and he then mentioned that he didn’t know about the specifics about the D-Dimer test and it’s interpretation. The patient then had a chest CT performed that ruled-out pulmonary embolism.
So, as you see, and will continue to see through this blog, there are many ways that physicians need our help and we, as laboratory professionals, must respond (before they kill someone else!).