LSU Internal Medicine Case Conference “What the Bullae !" 10/02/2012

1. LSU Internal Medicine Case Conference“What the Bullae!"10/02/2012 Jay Mansfield, MD PGY I Internal Medicine

2. Chief Complaint “Worsening shortness of breath” x several months

3. HPI • 76 year-old African American woman with significant past medical history of ischemic cardiomyopathy s/p AICD (last EF <20% in 12/2011), hypertension, hyperlipidemia, CKD stage III, peripheral vascular disease s/p left SFA stent (3 weeks prior) with left foot ischemic toes and multiple ulcers presented to the ED complaining of progressively worsening shortness of breath and fatigue over the past several months. • The patient started developing bilateral lower extremity edema and claudication.

4. HPI • She also developed orthopnea – having to sleep upright in a chair. • She had previously been able to ambulate about 1½ blocks easily but now can only walk a few steps before becoming short of breath. • She denied any chest pain, nausea, vomiting, fever or chills. • The patient is not able to recall all her medications and reports that she has not been adherent with her medications.

5. Past History • Past Medical History: • As above plus • Hypothyroidism • Surgical History: • Hysterectomy • ICD (2010) • Left SFA stents (3 weeks prior)

6. Past History • Allergies: • Penicillin/Sulfa  swelling and rash • Home Medications: • Aspirin 81 mg Daily • Clopidogrel 75 mg Daily • Simvastatin 40 mg QHS • Carvedilol 3.125 mg BID • Lantus 10 Units QHS • NovoLog 5 Units BID • Levothyroxine 50 mcg Daily • Ondansetron 4 mg PO q8hrs prn nausea

7. Past History • Family History • NC • Social History: • History of tobacco use >20 years previously with 5-pack year history • No ETOH, no illicit drugs • Lives alone • Has three daughters who live close and visit frequently

8. Past History • Health Maintenance: • PCP at LSU Medicine Clinic (Dr. Lacour) • Up-to-date on Influenza and Tdap • Unknown Pneumovax • Mammogram WNL (1/2012) • No colonoscopy • Review of Systems • Negative except per HPI

9. Vital Signs & Physical Exam

10. Vital Signs • Temp99° F • Pulse 93 • RR 20 • BP 131/57 • Pulse Ox 97% on RA • Weight 77 kg • Height 124 cm • BMI 50

11. Physical Exam I • General: • AAOx3, no acute distress • HEENT: • NCAT, PERRL, EOMI, clear oropharynx • Neck: • Supple. No Carotid bruits. JVP 12 cm H2O • Cardiovascular: • Regular rate and rhythm. No murmurs or rubs.

12. Physical Exam II • Pulmonary: • CTA bilaterally, no wheezes/rhonchi/crackles • Abdomen: • Nondistended, bowel sounds present, soft , non tender, obese • Extremity: • Dorsalispedis and Posterior tibial pulses not palpable. 2+femoral and radial pulses bilaterally. 2+ pitting edema bilaterally in lower extremities to lower back. 1+pitting edema in LUE. No palpable cords.

13. Physical Exam III • Skin: • No rashs, no bruises. • Left foot bandaged with multiple ischemic toes and wounds with purple stained skin from gentian violet preparation • Neurologic: • Face symmetric, tongue and uvula midline. • Hearing grossly intact. • Muscle strength 5/5 x 4 • Decreased sensation to pain and light touch over lower extremities especially feet bilaterally

14. Laboratory Data Day of Admission

15. Admit Laboratory Data I • WBC 12.4 (4.5-11.0) • Hgb 12.4 • Hct 39.7 • PLT 161 • MCV 74.8 (80-100) • RDW 17.8 (11.5-14.5) • Seg 80% • Bands 13% • Lymphs 1% • Monos 5% • Basophils 1%

16. Admit Laboratory Data II • Na 136 • K 4.5 • Cl 104 • Bicarbonate 21 (24-32) • BUN 30 (7-25) • Creatinine1.60 (0.5-1.10) • GFR 38 (>60) • Glucose 239 (65-99) • Ca++ 8.99.78 • Mg++ 1.9 • Phos 3.4

17. Admit Laboratory Data III • Total Protein 6.8 • Albumin 2.9 (3.4-5.0) • Total Bilirubin2.5 (<1.3) • AST 34 • Alkaline Phosphatase 114 • ALT 14 • BNP 3928 (<100) • TSH 4.52 • Free T4 0.77

18. EKG Day of Admission

20. EKG • First degree A-V block • Cannot rule out anterior myocardial infarction, age undetermined • Low QRS voltage in limb leads • No significant change from previous tracing

21. Chest X-Ray Day of Admission

24. CXR “Dual lead pacemaker again noted. The cardiomediastinal silhouette is stable with calcifications of the aortic knob and four-chamber cardiac enlargement. Bronchovascular marking pattern is unchanged. There is no evidence of pulmonary edema. The lungs are clear. There is no focal airspace consolidation, pleural effusion, or evidence of pneumothorax. Again noted is osteopenia and thoracic kyphosis.”

25. Hospital Day 1

26. Initial Management • Patient was admitted to Medicine • IV furosemide 40mg q12 hours initiated with strict I/O’s • Home medications continued

27. Hospital Day #3 Patient was noted by Primary Care team to have developed multiple hemorrhagic bullae on her right lower extremity She was also noted to have altered mental status Medical ICU, General Surgery and Infectious Disease services were consulted Labs, cultures, and ABG were obtained Patient was placed on NRB Patient was empirically started on Vancomycin, Clindamycin, and Ciprofloxacin

28. Vital Signs Temp 97° F (96-99.9 ° F) Pulse 98 RR 20 BP 123/63 Pulse Ox 96% on 3L NC

29. Physical Exam I • General: • Awake, lethargic, no acute distress • HEENT: • NCAT, PERRL, EOMI, clear oropharynx • Cardiovascular: • Regular rate and rhythm. No murmurs or rubs. • Pulmonary: • CTA bilaterally, diffuse expiratory wheezes present; no crackles, good air movement • Abdomen: • Nondistended, obese, bowel sounds present, soft , non tender

30. Physical Exam II • Extremity: • 2+ Radial pulses bilaterally. PT and DPs not palpable secondary to edema. 2+ pitting edema LE bilaterally to upper thighs. Left foot dressed in clean bandage. Multiple ischemic toes on Left foot. • Skin: • Multiple hemorrhagic bullae to anterior and medial aspect of RLE measuring 4x2cm. Posterior aspect of RLE near popliteal fossa where bullae erupted, weeping serosanguinous fluid with associated erythema and warmth.

31. Laboratory Data I Day #3 • WBC 2.6 (4.5-11.0) • Hgb 13.8 • Hct 43.6 • PLT 110 (130-400) • MCV 73.7 (80-100) • RDW 18.5 (11.5-14.5) • Seg 52% • Bands 13% • Lymphs 17% • Monos 16% • Basophils 1%

32. Laboratory Data II Day #3 • ABG 7.45/40/235/28/100% on 100% NRB Na 137 K 3.7 Cl 104 Bicarbonate 23 (24-32) BUN 29 Creatinine1.24 (0.5-1.10) GFR 51 (>60) Glucose 38(65-99) Ca++ 7.99.66 Mg++ 1.5 Phos 3.4 Blood cultures pending

33. Laboratory Data III Day #3 Total Protein 4.8 (6.0-8.0) Albumin 1.8 (3.4-5.0) Total Bilirubin2.7 (<1.3) AST 31 Alkaline Phosphatase 58 ALT 12 INR 2.0 (0.9-1.1) PT 21.7 (9-12.7) PTT 40.3 (24-37) Lactic Acid 1.6

34. Hospital Course: Day #3 Patient was given a total of 2 amps of D50 and some juice. Patient’s mental status returned to baseline. Repeat accucheck was 96. Patient underwent Ultrasound of right lower extremity – no DVT Patient was transferred to MICU for continued monitoring and management

35. Hospital Course: Day #3 • Transfer Antibiotic Medications: • Ciprofloxacin • Vancomycin • Clindamycin • Tigecycline

36. Hospital Course: Day #3 • Patient’s bullae began to desquamate and increase in number: affected anterior thigh area measured 8x4cm, posterior fossa skin involvement measured ~12cm in length • Patient had no mucosal involvement • New bullae appeared on patient’s suprapubic area with notable erythema and extreme tenderness 4x2cm • Right upper extremity became more edematous and extremely tender to touch, no bullae were noted, increased erythema noted in RUE antecubital fossa

37. Hospital Course: Day #3 • Dermatology was consulted and performed bedside examination and punch biopsy of one of the bullae on patient’s right lower extremity

38. Hemorrhagic Bullae Suprapubic

39. Anterior Thigh Right Lower Extremity

40. Medial Right Lower Extremity

41. Lateral Right Lower Extremity

42. Right Upper Extremity

43. Hospital Course Morning Day #4 • Patient stated she felt better. • Patient only complaining of pain in right arm and right hand • Oriented to person, place. Confused about exact date. • Small bullae noted in RUE antecubital fossa measuring 0.5x0.5cm • Other bullae and lesions appeared stable

44. Laboratory Data I Morning Day #4 • WBC 2.7 (4.5-11.0) • Hgb 12.9 • Hct 40.1 • PLT 111 (130-400) • Seg 71% • Bands 8% • Lymphs 13% • Monos 8% • Basophils 0%

45. Laboratory Data II Morning Day #4 • Ca++ 7.49.32 • Mg++ 1.4 • Phos 4.5 • Na 139 • K 4.4 • Cl 101 • Bicarbonate 25 • BUN 31 (7-25) • Creatinine1.55 (0.5-1.10) • GFR 40 (>60) • Glucose 92 • Anion Gap 18 (<10)

46. Laboratory Data III Day #3 Total Protein 4.2 (6-8) Albumin 1.6 (3.4-5.0) Total Bilirubin3.2 (<1.4) AST 61 (<45) Alkaline Phosphatase 44 ALT 15 BNP 3923 (<100) Lactic Acid 4.2 (0.3-2.4)

47. Hospital Course: Day #4 Patient became hypotensive requiring pressor support with total of 2 pressors: Levophed and Vasopressin Patient became more altered and was intubated to protect her airway Patient’s UOP significantly declined despite being on a lasix drip Patient was transfused albumin to help with diuresis

48. Hospital Course: Day #4 X-Ray of Right Lower Extremity revealed extensive edema, no subcutaneous emphysema

49. Significant Laboratory Data Day #4 Lactic Acid 1.6  4.2  10.4 Bicarbonate 21  25  12  6 Creatinine 1.24  1.55  1.95  2.41 WBC 2.6  2.7  10.1  14.3 Bandemia 13% 27% 8%  35% Platelets 110  131  111  97  49 INR 2  3.9 PT 21.7  43.1 CK 608 CRP 16.9 Troponin 1.88

50. Cont….. Patient became bradycardic and hypotensive, then became pulseless Patient was resuscitated with chest compressions and epinephrine Patient’s family decided to make the patient DNR if another code were to occur Patient became hypotensive again despite pressor support and died