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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Benjamin Eckhardt, MD PGY-3 October 6, 2010. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Benjamin Eckhardt, MD PGY-3 October 6, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 39-year-old man presenting with three days of fever, cough, and shortness of breath.

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient reported abrupt onset of subjective fevers, chills and headaches three days prior to admission. • He noted his cough to be progressively worsening with minimal sputum production. • On the day of admission, the patient’s symptoms progressed to include shortness of breath.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • None • Past Surgical History: • None • Social History: • From China, came to the United States four years prior to admission • Works in a restaurant • Denies recent travel or sick contacts • Denies toxic habits • Family History: • noncontributory • Allergies: No Known Drug Allergies • Denies any Medications

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Ill-appearing man in moderate respiratory distress • Vital Signs: T:103.9 BP:104/49 HR:126 RR:25 • O2 Sat: 83% on room air → 97% on • 100% non-re-breather • Course rhonchi throughout lung fields, no wheezing • Cool extremities • The remainder of Physical Exam was normal

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: White blood cells 7, 88% Neutrophils • Remainder of CBC was within normal limits • Hepatic Function Panel: AST: 98, ALT: 64 • Remainder of LFTs were within normal limits • Basic Metabolic Panel was within normal limits

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Lactate Dehydrogenase: 629 (110-225) Influenza A Ag: positive Influenza B Ag: negative Blood cultures and Urine cultures: No Growth

  8. Admission Chest X-Ray UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Cat Scan UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Cat Scan UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. Cat Scan UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis Influenza pneumonia with Acute Respiratory Distress Syndrome

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • The patient’s respiratory status worsened in the emergency room requiring intubation • The patient was started broad spectrum anti-microbials, and admitted to the medical intensive care unit. • The antimicrobials included: • Oseltamivir 150mg twice daily • Vancomycin 1g twice daily • Piperacillin/tazobactam 4.5g four times daily • Azithromycin 500mg daily

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • The patient remained febrile and dependent on ventilatory support after completing a five day course of oseltamivir and azithromycin • Hospital 7: Due to the patient’s persistent fevers he was switched to imipenem and restarted on the anti-virals oseltamivir and rimantidine

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital day 8: Oseltamivir was replaced by intravenous peramiver after being acquired from the Centers for Disease Control • Blood cultures, urine cultures, tracheal aspirate cultures, Human Immunodeficiency Virus testing, sputum Acid Fast Bacilli testing and urine legionella antigen were all negative

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 12: A bronchoscopy was performed with negative gram stain, Acid Fast Bacilli, Respiratory Syncytial Virus Polymerase Chain Reaction, bacterial culture and viral culture • Hospital Day 15: Antibiotics and antivirals were discontinued for worsening pancytopenia

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 16: Antiobiotics were restarted (cefepime then tigecycline) for neutropenic fever • Hospital Day 19-34: The patient’s Hemodynamics improved and vasopressors were weaned off. His fevers abated and his respiratory status improved allowing for capping of his tracheostomy. Additionally the patient’s blood counts improved and the patient was discharged home on hospital day 34.

  18. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Influenza pneumonia complicated by acute respiratory distress syndrome • Pancytopenia likely secondary to infection versus medication effect.

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