General Medical - Soccer

Abstract

HISTORY: During freshman pre-participation evaluation, blood panel revealed high ferritin levels (517.6 ng/mL) in an 18-year old Division-I female soccer player. Retest values confirmed levels at 570.7 ng/mL; she was referred to team physician. Following clearance for activity, she was participating in strenuous exercise and experienced vision change, severe headache, and lightheadedness. Symptoms lasted roughly 90 min. To relieve symptoms, she was removed from practice and placed in a dark, quiet room. She began bi-weekly 500mL bloodletting treatments in efforts to decrease ferritin levels. Four more vision change episodes have occurred since initial treatment. Symptoms lasted 30-90 min with the aid of Nodolor 65/100/325mg. PHYSICAL EXAMINATION: After first vision change episode, she underwent an EKG, CT, chest radiograph, and CBC blood panel. All results were within normal limits. She had a negative eye exam. No abnormalities with brain MRI but MRA showed a small benign left maxillary sinus mucosal retention cyst. Several CBC blood panel and ferritin blood tests were taken; demonstrating consistent elevated ferritin (range: 397.6-753.0 ng/mL). A hematologist ordered regular bi-weekly phlebotomy treatments consisting of 500mL blood draws. Following the second vision change episode, a full cardiac evaluation was ordered including an echocardiogram, EKG, 30-day heart monitor, exercise stress test, and table tilt test. Monthly ferritin blood tests are performed to determine if phlebotomy treatments are needed to maintain ferritin levels. DIFFERENTIAL DIAGNOSIS: 1. Dehydration 2. Head Injury 3. Migraines 4. Cardiac Condition 5. Hereditary Hemochromotosis TEST AND RESULTS: EKG, echocardiogram, Heart Monitoring, Exercise Stress Test, Table Tilt Test •Normal sinus rhythm, no evidence of ischemia CT brain, MRI, MRA •Small left maxillary sinus mucosal retention cyst, no evidence of aneurysm or vascular stenosis Chest X-ray •Normal Ferritin Blood Test •Elevated Ferritin level, 397.6-753.0 ng/mL FINAL WORKING DIAGNOSIS: Hereditary Hemochromotosis TREATMENT AND OUTCOMES: 1. Phlebotomy Treatments A. Initial phlebotomy treatments performed bi-weekly, 500mL drawn B. Activity monitored C. Nodolor 65/100/325mg taken at immediate onset of symptoms, then 1 every hour until symptoms resolve