Nyu medical grand rounds clinical vignette
This presentation is the property of its rightful owner.
Sponsored Links
1 / 16

NYU Medical Grand Rounds Clinical Vignette PowerPoint PPT Presentation


  • 48 Views
  • Uploaded on
  • Presentation posted in: General

NYU Medical Grand Rounds Clinical Vignette. Mark H. Adelman, M.D. PGY-2 2/19/13. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 43 year old man presents with headache, neck pain for approximately one week.

Download Presentation

NYU Medical Grand Rounds Clinical Vignette

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Mark H. Adelman, M.D.

PGY-2

2/19/13

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS


Chief complaint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 43 year old man presents with headache, neck pain for approximately one week


History of present illness

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Diagnosed with HIV in 2002, on HAART until he lost insurance in 2009

  • Doing well until 10 days prior to admission, felt like there was “fluid swishing in my ears”

  • Four days later, vomited multiple times, began to experience headache and neck stiffness


History of present illness1

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Presented to ER, head CT, left AMA prior to complete evaluation

  • Headache, neck stiffness, nausea/vomiting continued

  • No relief with naproxen, ibuprofen

  • Returned to ER for unremitting headache


Additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Past Medical History:

    • Bipolar II

  • Past Surgical History:

    • Hernia repair as a child

  • Social History:

    • No tobacco. Rare alcohol. Infrequent intranasal cocaine, semi-weekly cannabis use

    • Sex with men

  • Family History:

    • noncontributory

  • Allergies:

    • No known drug allergies

  • Medications:

    • Naproxen, ibuprofen as needed


Physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • General: Well appearing man, alert, in mild distress

  • Vital Signs: T: 97.5, BP: 125/78, HR: 55,

  • RR: 16, O2 sat: 96%RA

  • Neck pain with flexion/extension

  • Remainder of Physical Exam was normal


Laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CBC: Hemoglobin 16.7

    • Remainder of CBC was within normal limits

  • Basic metabolic panel: Potassium 3.5

    • Remainder of basic was within normal limits

  • Hepatic panel: ALT 74

    • Remainder of hepatic panel was within normal limits


Laboratory findings1

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CSF

    • Opening pressure 37

    • 12 WBCs (84% lymphocytes, 16% monocytes)

    • Protein 64

    • India ink, culture, cryptococcal antigen, HSV PCR pending

  • Blood cultures: pending

  • CD4 count and HIV-1 RNA: pending


Other studies

Other Studies

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Chest X-Ray: 1cm nodular opacity in right midlung

  • CT head: no acute intracranial findings


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Working or Differential Diagnosis

  • Cryptococcal meningitis

  • Viral meningitis

  • HSV encephalitis


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 1:

    • Amphotericin, flucytosine. Acyclovir

  • Hospital Day 2:

    • CD4 count 52 (5%). HIV-1 RNA 28,400.

    • Trimethoprim-sulfamethoxazole

    • Repeat lumbar puncture


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 3:

    • CSF India ink stain + for cryptococcus

    • CSF cryptococcal antigen + (1:8,192)

    • Serum cryptococcal antigen + (1:32,768)

    • CT chest: Multiple round, nodular opacities right lower lobe. Mediastinal, pretracheal, right hilar lymphadenopathy


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 4:

    • Headache improved

    • HSV PCR negative. Acyclovir discontinued

    • HD#1 CSF fungal culture + for cryptococcus

  • Hospital Days 5-7

    • Induced sputum negative for AFB x3

    • HD#2 CSF fungal culture + for cryptococcus

    • Blood cultures + for cryptococcus

    • Bronchoscopy: BAL, transbronchial lymph node/lung biopsies negative for AFB, + for cryptococcus


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 8:

    • Repeat LP: opening pressure 36

    • Cryptococcal antigen 1:512. Culture negative. VDRL +

    • IV penicillin G

  • Hospital days 9-14

    • Recurrent headaches

    • serial LPs until opening pressure 20. Cultures negative

    • Right occipital lymphadenopathy


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 15

    • Amphotericin, flucytosine discontinued

    • Oral fluconazole started

  • Hospital Day 16

    • Fine needle aspiration of occipital lymph node

  • Hospital Day 18

    • IV penicillin discontinued

    • FNA + for cryptococcus

    • Discharged home with virology follow-up in one week


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Final Diagnosis

  • Disseminated cryptococcosis


  • Login