NYU Medical Grand Rounds Clinical Vignette

Benjamin Eckhardt, MD

PGY-3

October 6, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 39-year-old man presenting with three days of fever, cough, and shortness of breath.

Chief Complaint

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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

Lactate Dehydrogenase: 629 (110-225)

Influenza A Ag: positiveInfluenza B Ag: negative

Blood cultures and Urine cultures: No Growth

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Admission Chest X-Ray

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Cat Scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Cat Scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Cat Scan

Influenza pneumonia with Acute Respiratory Distress Syndrome

Working or Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Influenza pneumonia complicated by acute respiratory distress syndrome

•Pancytopenia likely secondary to infection versus medication effect.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS